Provider Demographics
NPI:1679396295
Name:GIACONA, CHARLES DEAN (PT)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:DEAN
Last Name:GIACONA
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 1:2012 SUGG DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-2734
Mailing Address - Country:US
Mailing Address - Phone:936-224-0263
Mailing Address - Fax:
Practice Address - Street 1:2201 MACARTHUR DR STE 100
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76708-3159
Practice Address - Country:US
Practice Address - Phone:254-202-8720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-02
Last Update Date:2024-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1379330225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist