Provider Demographics
NPI:1720381098
Name:CANGILOSE, JULIAN (LMT)
Entity Type:Individual
Prefix:
First Name:JULIAN
Middle Name:
Last Name:CANGILOSE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 664
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97528-0057
Mailing Address - Country:US
Mailing Address - Phone:541-660-5559
Mailing Address - Fax:541-474-6310
Practice Address - Street 1:1328 NW 6TH STREET
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1255
Practice Address - Country:US
Practice Address - Phone:541-660-5559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-08
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15467225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist