Healthcare Provider Details

I. General information

NPI: 1285255372
Provider Name (Legal Business Name): MARC GELINAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2020
Last Update Date: 04/30/2020
Certification Date: 04/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 EGRET LN
SOUTHLAKE TX
76092-5800
US

IV. Provider business mailing address

1710 EGRET LN
SOUTHLAKE TX
76092-5800
US

V. Phone/Fax

Practice location:
  • Phone: 817-821-5494
  • Fax:
Mailing address:
  • Phone: 817-821-5494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1082683
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: