1548561152 NPI number — MRS. MARY AUDRIENE GALLEGOS S.S.W.

Table of content: MRS. MARY AUDRIENE GALLEGOS S.S.W. (NPI 1548561152)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548561152 NPI number — MRS. MARY AUDRIENE GALLEGOS S.S.W.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GALLEGOS
Provider First Name:
MARY
Provider Middle Name:
AUDRIENE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
S.S.W.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FULLER
Provider Other First Name:
MARY
Provider Other Middle Name:
AUDRIENE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1548561152
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
663 W 950 S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRIGHAM CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84302-3021
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-734-9449
Provider Business Mailing Address Fax Number:
435-723-4851

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
663 W 950 S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIGHAM CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84302-3021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-734-9449
Provider Business Practice Location Address Fax Number:
435-723-4851
Provider Enumeration Date:
11/12/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  7544766-3503 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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