Healthcare Provider Details

I. General information

NPI: 1225708761
Provider Name (Legal Business Name): VIVIAN FAITH GILLIS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2021
Last Update Date: 11/01/2021
Certification Date: 10/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 NO NAME AVE
AUGUSTA FL
33635
US

IV. Provider business mailing address

PO BOX 2661
BLAIRSVILLE GA
30514-2661
US

V. Phone/Fax

Practice location:
  • Phone: 813-000-0000
  • Fax:
Mailing address:
  • Phone: 602-463-0135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberTA7686
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: