Provider Demographics
NPI:1871711770
Name:GARY M. DEACON
Entity type:Organization
Organization Name:GARY M. DEACON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEACON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:209-532-6463
Mailing Address - Street 1:181 FAIRVIEW LN
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-4809
Mailing Address - Country:US
Mailing Address - Phone:209-532-6463
Mailing Address - Fax:209-532-3420
Practice Address - Street 1:181 FAIRVIEW LN
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-4809
Practice Address - Country:US
Practice Address - Phone:209-532-6463
Practice Address - Fax:209-532-3420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT11939261QP2000X
CAPT 11939332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ20662ZMedicare PIN
CAX59306Medicare UPIN
CA4619230001Medicare NSC