Healthcare Provider Details

I. General information

NPI: 1871422204
Provider Name (Legal Business Name): DEVON GALLEGOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2123 E 11TH ST
PUEBLO CO
81001-3434
US

IV. Provider business mailing address

2123 E 11TH ST
PUEBLO CO
81001-3434
US

V. Phone/Fax

Practice location:
  • Phone: 719-248-8747
  • Fax: 719-248-8747
Mailing address:
  • Phone: 719-248-8747
  • Fax: 719-248-8747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: