Healthcare Provider Details

I. General information

NPI: 1275889586
Provider Name (Legal Business Name): MR. MIGUEL ENRIQUE GALLARZO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2012
Last Update Date: 07/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5801 E BEVERLY BLVD
LOS ANGELES CA
90022-2805
US

IV. Provider business mailing address

5801 E BEVERLY BLVD
LOS ANGELES CA
90022-2805
US

V. Phone/Fax

Practice location:
  • Phone: 323-722-4529
  • Fax: 323-722-4450
Mailing address:
  • Phone: 323-722-4529
  • Fax: 323-722-4450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: