Provider Demographics
NPI:1376860445
Name:GALLOWAY CHIROPRACTIC AND SPORTS REHAB, LLC
Entity Type:Organization
Organization Name:GALLOWAY CHIROPRACTIC AND SPORTS REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLOWAY
Authorized Official - Suffix:III
Authorized Official - Credentials:DC
Authorized Official - Phone:813-253-3111
Mailing Address - Street 1:6963 E FOWLER AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33617-1714
Mailing Address - Country:US
Mailing Address - Phone:813-253-3111
Mailing Address - Fax:813-514-0108
Practice Address - Street 1:6963 E FOWLER AVE
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33617-1714
Practice Address - Country:US
Practice Address - Phone:813-253-3111
Practice Address - Fax:813-514-0108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-28
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9352111NS0005X
FLME101995207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAG891ZMedicare UPIN