Healthcare Provider Details

I. General information

NPI: 1306929328
Provider Name (Legal Business Name): GARY DEACON P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 03/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 FAIRVIEW LN
SONORA CA
95370-4809
US

IV. Provider business mailing address

181 FAIRVIEW LN
SONORA CA
95370-4809
US

V. Phone/Fax

Practice location:
  • Phone: 209-532-6463
  • Fax: 209-532-3420
Mailing address:
  • Phone: 209-532-6463
  • Fax: 209-532-3420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 11939
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: