Healthcare Provider Details

I. General information

NPI: 1235304577
Provider Name (Legal Business Name): JOHN SCHUYLER GAMMON II LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2008
Last Update Date: 04/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

488 BULL RUN RD
LISBON NY
13658-3257
US

IV. Provider business mailing address

488 BULL RUN RD
LISBON NY
13658-3257
US

V. Phone/Fax

Practice location:
  • Phone: 315-393-4204
  • Fax:
Mailing address:
  • Phone: 315-393-4204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number0176961
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: