Healthcare Provider Details

I. General information

NPI: 1154518918
Provider Name (Legal Business Name): GARY THOMAS WATERS L.M.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2007
Last Update Date: 09/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9719 DEAN ACRE CT
ORLANDO FL
32825-6557
US

IV. Provider business mailing address

9719 DEAN ACRE CT
ORLANDO FL
32825-6557
US

V. Phone/Fax

Practice location:
  • Phone: 407-497-9235
  • Fax: 407-249-2167
Mailing address:
  • Phone: 407-497-9235
  • Fax: 407-249-2167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberMA24290
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: