Provider Demographics
NPI:1558898296
Name:TEAM ACG LLC
Entity Type:Organization
Organization Name:TEAM ACG LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN, MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:GALLAGHER
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, LDN
Authorized Official - Phone:321-255-7841
Mailing Address - Street 1:5247 INDIGO CROSSING DR
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-6053
Mailing Address - Country:US
Mailing Address - Phone:321-255-7841
Mailing Address - Fax:888-972-3871
Practice Address - Street 1:3190 SUNTREE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-5741
Practice Address - Country:US
Practice Address - Phone:321-255-7841
Practice Address - Fax:888-972-3871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-12
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND3586133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, MetabolicGroup - Multi-Specialty