Healthcare Provider Details

I. General information

NPI: 1508774456
Provider Name (Legal Business Name): SOFIA GALLEGOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7890 HAVEN AVE STE 10
RANCHO CUCAMONGA CA
91730-3072
US

IV. Provider business mailing address

1479 REDBUD AVE
BANNING CA
92220-3120
US

V. Phone/Fax

Practice location:
  • Phone: 909-569-3913
  • Fax:
Mailing address:
  • Phone: 951-755-9401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number102139
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: