Provider Demographics
NPI:1710020219
Name:GALLEGOS, GABRIEL MANUEL
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:MANUEL
Last Name:GALLEGOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3350 S FAIRWAY ST
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93277-8109
Mailing Address - Country:US
Mailing Address - Phone:155-973-0922
Mailing Address - Fax:559-730-9937
Practice Address - Street 1:3350 S FAIRWAY ST
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93277-8109
Practice Address - Country:US
Practice Address - Phone:155-973-0922
Practice Address - Fax:559-730-9937
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1558483198OtherMEDI-CAL