Provider Demographics
NPI:1750568861
Name:MONTESCLAROS, GLORIA ANGELA (PT)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:ANGELA
Last Name:MONTESCLAROS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 W AVENIDA DEL RIO
Mailing Address - Street 2:
Mailing Address - City:CLEWISTON
Mailing Address - State:FL
Mailing Address - Zip Code:33440-0225
Mailing Address - Country:US
Mailing Address - Phone:863-983-9979
Mailing Address - Fax:863-983-5655
Practice Address - Street 1:501 E SUGARLAND HWY
Practice Address - Street 2:
Practice Address - City:CLEWISTON
Practice Address - State:FL
Practice Address - Zip Code:33440-3210
Practice Address - Country:US
Practice Address - Phone:863-983-9979
Practice Address - Fax:863-983-5655
Is Sole Proprietor?:No
Enumeration Date:2008-01-31
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT20447225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBF979ZMedicare PIN