Provider Demographics
NPI:1891021002
Name:GARGALLO, MICHELE MOCTEZUMA
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:MOCTEZUMA
Last Name:GARGALLO
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 1:8585 NW 6 LANE
Mailing Address - Street 2:209
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126
Mailing Address - Country:US
Mailing Address - Phone:305-527-3772
Mailing Address - Fax:
Practice Address - Street 1:8585 NW 6 LANE
Practice Address - Street 2:209
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126
Practice Address - Country:US
Practice Address - Phone:305-527-3772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-22
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA37745172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA37745OtherMASSAGE THERAPIST