Provider Demographics
NPI:1699195842
Name:GILLILAND, R CHAD (ATC, MSM, LAT)
Entity Type:Individual
Prefix:
First Name:R CHAD
Middle Name:
Last Name:GILLILAND
Suffix:
Gender:M
Credentials:ATC, MSM, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 GULF BREEZE PKWY
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32561-4838
Mailing Address - Country:US
Mailing Address - Phone:850-916-8702
Mailing Address - Fax:
Practice Address - Street 1:1020 GULF BREEZE PKWY
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-4838
Practice Address - Country:US
Practice Address - Phone:850-916-8702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-25
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 7852255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer