Provider Demographics
NPI:1720003171
Name:COX, GREGORY (RPT)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:COX
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12241 INDUSTRIAL BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-7794
Mailing Address - Country:US
Mailing Address - Phone:800-489-6905
Mailing Address - Fax:
Practice Address - Street 1:12241 INDUSTRIAL BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-7794
Practice Address - Country:US
Practice Address - Phone:800-489-6905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16294225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14812Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER