Healthcare Provider Details

I. General information

NPI: 1114369907
Provider Name (Legal Business Name): MEDICAL GALLERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2013
Last Update Date: 08/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 N WAUKESHA ST
BONIFAY FL
32425-2245
US

IV. Provider business mailing address

217 N WAUKESHA ST
BONIFAY FL
32425-2245
US

V. Phone/Fax

Practice location:
  • Phone: 850-547-6186
  • Fax: 855-899-5726
Mailing address:
  • Phone: 850-547-6186
  • Fax: 855-899-5726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: MR. RYAN N HELMS
Title or Position: OWNER/MANAGER
Credential: CPC
Phone: 850-547-6186