Healthcare Provider Details

I. General information

NPI: 1841779774
Provider Name (Legal Business Name): GILBERT GALLAHAR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2018
Last Update Date: 06/29/2021
Certification Date: 06/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1171 E LINDA LN
CHANDLER AZ
85225-3971
US

IV. Provider business mailing address

1393 HILL ST
RADCLIFF KY
40160-9138
US

V. Phone/Fax

Practice location:
  • Phone: 310-971-7673
  • Fax:
Mailing address:
  • Phone: 310-971-7673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: