Healthcare Provider Details

I. General information

NPI: 1689948606
Provider Name (Legal Business Name): ENRIQUE GALLARDO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2012
Last Update Date: 03/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 E FOOTHILL BLVD
PASADENA CA
91107-3406
US

IV. Provider business mailing address

3010 VINELAND AVE APT. #12
BALDWIN PARK CA
91706-5040
US

V. Phone/Fax

Practice location:
  • Phone: 626-255-5874
  • Fax:
Mailing address:
  • Phone: 626-476-4444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: