Healthcare Provider Details

I. General information

NPI: 1275362089
Provider Name (Legal Business Name): MARIAH GALLEGOS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2024
Last Update Date: 11/19/2025
Certification Date: 11/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 SAN PEDRO DR NE # 118
ALBUQUERQUE NM
87110-4131
US

IV. Provider business mailing address

2501 SAN PEDRO DR NE # 118
ALBUQUERQUE NM
87110-4131
US

V. Phone/Fax

Practice location:
  • Phone: 505-249-3826
  • Fax: 505-212-4610
Mailing address:
  • Phone: 505-249-3826
  • Fax: 505-212-4610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: