Provider Demographics
NPI:1982914172
Name:GALLEGOS, MARY LOUISE (MPT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 W US HIGHWAY 30
Mailing Address - Street 2:SUITE A
Mailing Address - City:CARROLL
Mailing Address - State:IA
Mailing Address - Zip Code:51401-3364
Mailing Address - Country:US
Mailing Address - Phone:712-794-7204
Mailing Address - Fax:888-746-8588
Practice Address - Street 1:1205 W US HIGHWAY 30
Practice Address - Street 2:SUITE A
Practice Address - City:CARROLL
Practice Address - State:IA
Practice Address - Zip Code:51401-3364
Practice Address - Country:US
Practice Address - Phone:712-794-7204
Practice Address - Fax:888-746-8588
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-21
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05006711A282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital