Provider Demographics
NPI:1629303607
Name:TAGLE, GARRY GABIONZA (PT)
Entity Type:Individual
Prefix:MR
First Name:GARRY
Middle Name:GABIONZA
Last Name:TAGLE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 N MARION ST
Mailing Address - Street 2:UNIT 1A
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1936
Mailing Address - Country:US
Mailing Address - Phone:708-386-0136
Mailing Address - Fax:
Practice Address - Street 1:221 N MARION ST
Practice Address - Street 2:UNIT 1A
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-1936
Practice Address - Country:US
Practice Address - Phone:708-386-0136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-09
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070013388225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist