1003583048 NPI number — LAURA MARIA GARCIA GALLO

Table of content: LAURA MARIA GARCIA GALLO (NPI 1003583048)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003583048 NPI number — LAURA MARIA GARCIA GALLO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GARCIA GALLO
Provider First Name:
LAURA
Provider Middle Name:
MARIA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003583048
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4348 LA JARA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-689-8670
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6379 CANYON DAWN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89108-0801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-417-2987
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/26/2021

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: 3747P1801X , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1487056909 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".