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General NPI Number Information
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NPI Number | 1588946123
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Entity Type | Individual
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Provider Name | GARY ROBERT LUNDAHL B.S.
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Gender | Male
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Dates
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Enumeration Date | 09/09/2011
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Last Update Date | 09/13/2011
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Provider Practice Location Address
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Address Line | 4148 MILLER ST
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City | WILLIAMSON
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State | NY
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Zip | 14589-9713
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Country | US
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Telephone | 315-589-9668
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Fax |
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Provider Business Mailing Address
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Address Line | 1245 SAGEBROOK WAY
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City | WEBSTER
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State | NY
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Zip | 14580-9416
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Country | US
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Telephone | 585-216-9991
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 020455
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License Number State | NY
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