Healthcare Provider Details

I. General information

NPI: 1114002219
Provider Name (Legal Business Name): GALLUP LIMB AND BRACE CO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 01/25/2024
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

927 WEST AZTEC AVENUE
GALLUP NM
87301
US

IV. Provider business mailing address

927 WEST AZTEC AVENUE
GALLUP NM
87301
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-5756
  • Fax: 505-722-6726
Mailing address:
  • Phone: 505-722-5756
  • Fax: 505-722-6726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberCP002174
License Number State

VIII. Authorized Official

Name: JUSTIN MARSHALL
Title or Position: PRESIDENT/OWNER
Credential: ABC COA
Phone: 505-722-5756