Healthcare Provider Details

I. General information

NPI: 1184725095
Provider Name (Legal Business Name): KENNETH L GALLEGOS CSFA/ CST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/22/2021
Certification Date: 07/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6903 S PICADILLY ST
AURORA CO
80016-2341
US

IV. Provider business mailing address

PO BOX 471973
AURORA CO
80047-1973
US

V. Phone/Fax

Practice location:
  • Phone: 303-525-1698
  • Fax: 720-500-2142
Mailing address:
  • Phone: 303-525-1698
  • Fax: 303-827-3401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number178983
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: