Provider Demographics
NPI:1649393919
Name:GALLEGO, GUSTAVO (LMT)
Entity type:Individual
Prefix:MR
First Name:GUSTAVO
Middle Name:
Last Name:GALLEGO
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6447 BOCA CIR
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-7812
Mailing Address - Country:US
Mailing Address - Phone:954-243-1600
Mailing Address - Fax:
Practice Address - Street 1:6447 BOCA CIR
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-7812
Practice Address - Country:US
Practice Address - Phone:954-243-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA41838225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist