Healthcare Provider Details

I. General information

NPI: 1942938337
Provider Name (Legal Business Name): MATT GALLEGOS CPSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2022
Last Update Date: 08/12/2022
Certification Date: 08/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 W MAIN ST
FARMINGTON NM
87401
US

IV. Provider business mailing address

653 W ARRINGTON ST
FARMINGTON NM
87401-8513
US

V. Phone/Fax

Practice location:
  • Phone: 505-772-9663
  • Fax:
Mailing address:
  • Phone: 505-258-9313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: