Healthcare Provider Details

I. General information

NPI: 1417328063
Provider Name (Legal Business Name): NOEM CLAY GALLEGO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2015
Last Update Date: 09/13/2021
Certification Date: 08/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34101 BUILDING 14, FARENHOLT AVENUE
SAN DIEGO CA
92134
US

IV. Provider business mailing address

34101 BUILDING 14, FARENHOLT AVENUE
SAN DIEGO CA
92134
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-9712
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: