MEDICARE: TEAM ACG LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133VN1006X	Metabolic Nutrition Registered Dietitian	ND3586	FL

General Provider Information

NPI Number	:	1558898296
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TEAM ACG LLC

Provider Business Mailing Address
First Line	:	5247 INDIGO CROSSING DR
Second Line	:
City	:	ROCKLEDGE
State	:	FL
Zip	:	32955-6053
Country	:	US
Telephone Number	:	321-255-7841
Fax Number	:	888-972-3871

Provider Business Practice Location Address
First Line	:	3190 SUNTREE BLVD STE 101
Second Line	:
City	:	ROCKLEDGE
State	:	FL
Zip	:	32955-5741
Country	:	US
Telephone Number	:	321-255-7841
Fax Number	:	888-972-3871

Authorized Official
Title or Position	:	REGISTERED DIETITIAN, MEMBER
Name	:	ANGELA MICHELLE GALLAGHER
Credential	:	RDN, LDN
Telephone Number	:	321-255-7841

Provider Enumeration Date	:	05/12/2017
Last Update Date	:	12/13/2017

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