Provider Demographics
NPI:1679546212
Name:GILLIS, GARRY (ATC)
Entity Type:Individual
Prefix:
First Name:GARRY
Middle Name:
Last Name:GILLIS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 S LILAC LOOP
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32259-1919
Mailing Address - Country:US
Mailing Address - Phone:904-536-0548
Mailing Address - Fax:904-264-8350
Practice Address - Street 1:540 KINGSLEY AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4847
Practice Address - Country:US
Practice Address - Phone:904-536-0548
Practice Address - Fax:904-264-8350
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL522255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer