Provider Demographics
NPI:1871522367
Name:STILES, GARY GLYNN JR (ATC, LAT)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:GLYNN
Last Name:STILES
Suffix:JR
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:258 LAKE BREEZE
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-6042
Mailing Address - Country:US
Mailing Address - Phone:407-322-7035
Mailing Address - Fax:
Practice Address - Street 1:1890 W COUNTY ROAD 419
Practice Address - Street 2:SUITE 1000
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-4402
Practice Address - Country:US
Practice Address - Phone:407-694-8354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 3562255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer