Healthcare Provider Details

I. General information

NPI: 1639090541
Provider Name (Legal Business Name): GARY GALLA TOLENTINO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2026
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1206 PARK TERRACE DR
ROCKFORD IL
61114-5943
US

IV. Provider business mailing address

1206 PARK TERRACE DR
ROCKFORD IL
61114-5943
US

V. Phone/Fax

Practice location:
  • Phone: 212-981-1977
  • Fax: 646-786-4026
Mailing address:
  • Phone: 212-981-1977
  • Fax: 646-786-4026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number889740
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: