Provider Demographics
NPI:1619286838
Name:GORI, FABIANO R (LMT)
Entity type:Individual
Prefix:
First Name:FABIANO
Middle Name:R
Last Name:GORI
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2630 FOUNTAIN VIEW DR
Mailing Address - Street 2:SUITE 142
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77057-7608
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2630 FOUNTAIN VIEW DR
Practice Address - Street 2:SUITE 142
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77057-7608
Practice Address - Country:US
Practice Address - Phone:281-827-0647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-05
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT038213225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXMT038213OtherTEXAS DEPARTMENT OF STATE HEALTH SERVICES