Provider Demographics
NPI:1497208029
Name:BLANCO, GABRIEL (DPT)
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:
Last Name:BLANCO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4302 PINE TRAIL LN
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-5357
Mailing Address - Country:US
Mailing Address - Phone:513-477-8891
Mailing Address - Fax:
Practice Address - Street 1:634 BACONS BRIDGE RD
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-4102
Practice Address - Country:US
Practice Address - Phone:843-821-2272
Practice Address - Fax:843-821-2274
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-01
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8271225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist