Healthcare Provider Details

I. General information

NPI: 1306355334
Provider Name (Legal Business Name): JEREMY GALLEGO ASPA ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2017
Last Update Date: 08/01/2026
Certification Date: 08/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 WASHINGTON AVE # 86
NEWPORT NEWS VA
23607-2700
US

IV. Provider business mailing address

1636 MILL OAK DR
VIRGINIA BEACH VA
23464-7920
US

V. Phone/Fax

Practice location:
  • Phone: 757-380-2000
  • Fax:
Mailing address:
  • Phone: 757-374-1837
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126002107
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: