Healthcare Provider Details

I. General information

NPI: 1376860445
Provider Name (Legal Business Name): GALLOWAY CHIROPRACTIC AND SPORTS REHAB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2010
Last Update Date: 10/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6963 E FOWLER AVE
TEMPLE TERRACE FL
33617-1714
US

IV. Provider business mailing address

6963 E FOWLER AVE
TEMPLE TERRACE FL
33617-1714
US

V. Phone/Fax

Practice location:
  • Phone: 813-253-3111
  • Fax: 813-514-0108
Mailing address:
  • Phone: 813-253-3111
  • Fax: 813-514-0108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberCH9352
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME101995
License Number StateFL

VIII. Authorized Official

Name: DR. RICHARD GALLOWAY III
Title or Position: CHIROPRACTOR
Credential: D.C.
Phone: 813-253-3111