Provider Demographics
NPI:1114369907
Name:MEDICAL GALLERY, LLC
Entity Type:Organization
Organization Name:MEDICAL GALLERY, LLC
Other - Org Name:THE MEDICAL GALLERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:HELMS
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:850-547-6186
Mailing Address - Street 1:217 N WAUKESHA ST
Mailing Address - Street 2:
Mailing Address - City:BONIFAY
Mailing Address - State:FL
Mailing Address - Zip Code:32425-2245
Mailing Address - Country:US
Mailing Address - Phone:850-547-6186
Mailing Address - Fax:855-899-5726
Practice Address - Street 1:217 N WAUKESHA ST
Practice Address - Street 2:
Practice Address - City:BONIFAY
Practice Address - State:FL
Practice Address - Zip Code:32425-2245
Practice Address - Country:US
Practice Address - Phone:850-547-6186
Practice Address - Fax:855-899-5726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-23
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010841400Medicaid
FL7088950001Medicare NSC