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NPI Code Detail

MEDICARE: GARRY GILLIS ATC

MEDICARE: GARRY GILLIS ATC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12255A2300XAthletic TrainerAL52FL

General Provider Information

NPI Number : 1679546212
Entity Type Code : Individual
Provider Name (Legal Business Name) : GARRY GILLIS ATC
Provider Business Mailing Address
First Line : 802 S LILAC LOOP
Second Line :
City : JACKSONVILLE
State : FL
Zip : 32259-1919
Country : US
Telephone Number : 904-536-0548
Fax Number : 904-264-8350
Provider Business Practice Location Address
First Line : 540 KINGSLEY AVE
Second Line :
City : ORANGE PARK
State : FL
Zip : 32073-4847
Country : US
Telephone Number : 904-536-0548
Fax Number : 904-264-8350
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/13/2006
Last Update Date : 07/08/2007

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