Healthcare Provider Details

I. General information

NPI: 1477124337
Provider Name (Legal Business Name): KENNY GALLEGOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2021
Last Update Date: 07/01/2021
Certification Date: 07/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 W COLTON AVE STE 585
REDLANDS CA
92374-2861
US

IV. Provider business mailing address

1255 W COLTON AVE STE 585
REDLANDS CA
92374-2861
US

V. Phone/Fax

Practice location:
  • Phone: 909-747-4344
  • Fax:
Mailing address:
  • Phone: 909-747-4344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number101497
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: