Healthcare Provider Details

I. General information

NPI: 1841567310
Provider Name (Legal Business Name): WENDY GALLEGOS, M.A. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2011
Last Update Date: 11/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 ASHLEY LN
CORRALES NM
87048-8940
US

IV. Provider business mailing address

420 ASHLEY LN
CORRALES NM
87048-8940
US

V. Phone/Fax

Practice location:
  • Phone: 505-898-2474
  • Fax: 505-899-8172
Mailing address:
  • Phone: 505-898-2474
  • Fax: 505-899-8172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number562
License Number StateNM

VIII. Authorized Official

Name: ROGER P WALDOCK
Title or Position: OFFICE MANAGER
Credential:
Phone: 505-898-2474