Provider Demographics
NPI:1245260769
Name:PEVNICK, GARY (PT)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:PEVNICK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 QUARTERDECK ST APT 3
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6700
Mailing Address - Country:US
Mailing Address - Phone:314-570-5153
Mailing Address - Fax:
Practice Address - Street 1:12655 W JEFFERSON BLVD FL 4
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-7008
Practice Address - Country:US
Practice Address - Phone:310-907-9215
Practice Address - Fax:310-953-3281
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO00394225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000025218Medicare PIN