MEDICARE: LUKE GAILLARD

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	164W00000X	Licensed Practical Nurse	025.0078863	VT

General Provider Information

NPI Number	:	1568737328
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUKE GAILLARD

Provider Business Mailing Address
First Line	:	182 HOLTON HILL
Second Line	:	PO BOX 473
City	:	HARDWICK
State	:	VT
Zip	:	05843-0473
Country	:	US
Telephone Number	:	802-498-8881
Fax Number	:

Provider Business Practice Location Address
First Line	:	324 SOUTH BAYLEY-HAZEN RD
Second Line	:
City	:	RYEGATE
State	:	VT
Zip	:	05042
Country	:	US
Telephone Number	:	802-584-4679
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/13/2012
Last Update Date	:	03/13/2012

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Directions to “ LUKE GAILLARD ” Practice Location

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