Provider Demographics
NPI:1376822957
Name:GANT, ROLAND C JR (BS)
Entity type:Individual
Prefix:
First Name:ROLAND
Middle Name:C
Last Name:GANT
Suffix:JR
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 W 5TH ST
Mailing Address - Street 2:# 220
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-3388
Mailing Address - Country:US
Mailing Address - Phone:424-250-5494
Mailing Address - Fax:
Practice Address - Street 1:3737 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:# 421
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-3513
Practice Address - Country:US
Practice Address - Phone:424-250-5494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-12
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner