Provider Demographics
NPI:1790466340
Name:GALLEGOS, LUCINDA ERCELLIA
Entity Type:Individual
Prefix:
First Name:LUCINDA
Middle Name:ERCELLIA
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1907 BONFORTE BLVD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-1759
Mailing Address - Country:US
Mailing Address - Phone:719-994-2091
Mailing Address - Fax:719-717-3500
Practice Address - Street 1:1907 BONFORTE BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-1759
Practice Address - Country:US
Practice Address - Phone:719-994-2091
Practice Address - Fax:719-717-3500
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications