Provider Demographics
NPI:1992219836
Name:GALLEGO HEALTH
Entity Type:Organization
Organization Name:GALLEGO HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HECTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLEGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-773-0657
Mailing Address - Street 1:PO BOX 19284
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71149-0284
Mailing Address - Country:US
Mailing Address - Phone:318-773-0657
Mailing Address - Fax:
Practice Address - Street 1:115 HALLETTE DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-2959
Practice Address - Country:US
Practice Address - Phone:318-773-0657
Practice Address - Fax:318-688-1559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-30
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA208256261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA208256OtherMEDICAL LICENSE