Provider Demographics
NPI:1710946454
Name:GANDIONGCO, GLEN S (PT)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:S
Last Name:GANDIONGCO
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 1:5312 SE 44TH CIR
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34480-4918
Mailing Address - Country:US
Mailing Address - Phone:352-873-9275
Mailing Address - Fax:352-873-9275
Practice Address - Street 1:1501 SE 24TH RD
Practice Address - Street 2:OAKHURST REHABILITATION & NURSING CENTER
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-6005
Practice Address - Country:US
Practice Address - Phone:352-629-8900
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9130225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist