Provider Demographics
NPI:1730519638
Name:INOCENCIO, GREGG
Entity type:Individual
Prefix:
First Name:GREGG
Middle Name:
Last Name:INOCENCIO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1409 S SALISBURY BLVD
Practice Address - Street 2:UNTIS C & D
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-7151
Practice Address - Country:US
Practice Address - Phone:667-330-1061
Practice Address - Fax:410-334-3730
Is Sole Proprietor?:No
Enumeration Date:2013-11-14
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0003104225100000X
MD24804225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD325422ZBL8Medicare PIN
DE346433Y0XMedicare PIN
DEP01391555Medicare PIN