Provider Demographics
NPI:1902880883
Name:GAVIOLA, CLIFFORD ANGCO (PT)
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:ANGCO
Last Name:GAVIOLA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:BOEING
Other - Middle Name:ANGCO
Other - Last Name:GAVIOLA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:5730 CORPORATE WAY STE 214
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-2032
Mailing Address - Country:US
Mailing Address - Phone:774-218-5585
Mailing Address - Fax:561-603-6450
Practice Address - Street 1:372 BROADWAY
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-5016
Practice Address - Country:US
Practice Address - Phone:781-485-1001
Practice Address - Fax:781-289-6820
Is Sole Proprietor?:No
Enumeration Date:2005-12-03
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16695225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1902880883Medicare UPIN
MAP00751148Medicare PIN