Provider Demographics
NPI:1053601393
Name:GAMBARU CORP
Entity type:Organization
Organization Name:GAMBARU CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOLORES
Authorized Official - Middle Name:I
Authorized Official - Last Name:KERSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:781-558-9565
Mailing Address - Street 1:999 BROADWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAUGUS
Mailing Address - State:MA
Mailing Address - Zip Code:01906-4521
Mailing Address - Country:US
Mailing Address - Phone:781-558-9565
Mailing Address - Fax:
Practice Address - Street 1:999 BROADWAY
Practice Address - Street 2:SUITE 100
Practice Address - City:SAUGUS
Practice Address - State:MA
Practice Address - Zip Code:01906-4521
Practice Address - Country:US
Practice Address - Phone:781-558-9565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251H1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHuman FactorsGroup - Multi-Specialty
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0324621Medicaid