Provider Demographics
NPI:1114002219
Name:GALLUP LIMB AND BRACE CO INC
Entity Type:Organization
Organization Name:GALLUP LIMB AND BRACE CO INC
Other - Org Name:GALLUP ARTIFICIAL LIMB AND BRACE CO INC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:ABC COA
Authorized Official - Phone:505-722-5756
Mailing Address - Street 1:927 WEST AZTEC AVENUE
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301
Mailing Address - Country:US
Mailing Address - Phone:505-722-5756
Mailing Address - Fax:505-722-6726
Practice Address - Street 1:927 WEST AZTEC AVENUE
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301
Practice Address - Country:US
Practice Address - Phone:505-722-5756
Practice Address - Fax:505-722-6726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CP002174224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMT6269Medicaid
AZ307852Medicaid
0264640001Medicare ID - Type Unspecified