Healthcare Provider Details

I. General information

NPI: 1053601393
Provider Name (Legal Business Name): GAMBARU CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2011
Last Update Date: 04/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 BROADWAY SUITE 100
SAUGUS MA
01906-4521
US

IV. Provider business mailing address

999 BROADWAY SUITE 100
SAUGUS MA
01906-4521
US

V. Phone/Fax

Practice location:
  • Phone: 781-558-9565
  • Fax:
Mailing address:
  • Phone: 781-558-9565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251H1300X
TaxonomyHuman Factors Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DOLORES I KERSHAW
Title or Position: PRESIDENT
Credential: OTR/L
Phone: 781-558-9565