Provider Demographics
NPI:1720253883
Name:CONDOLUCI, GARY L (LMT)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:L
Last Name:CONDOLUCI
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 1:4 HERITAGE ESTATES
Mailing Address - Street 2:
Mailing Address - City:ALBION
Mailing Address - State:NY
Mailing Address - Zip Code:14411
Mailing Address - Country:US
Mailing Address - Phone:585-727-1410
Mailing Address - Fax:585-798-0883
Practice Address - Street 1:11020 WEST CENTER ST EXT
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:NY
Practice Address - Zip Code:14103
Practice Address - Country:US
Practice Address - Phone:585-727-1410
Practice Address - Fax:585-798-0883
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018165225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist