Healthcare Provider Details

I. General information

NPI: 1568737328
Provider Name (Legal Business Name): LUKE GAILLARD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2012
Last Update Date: 03/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 SOUTH BAYLEY-HAZEN RD
RYEGATE VT
05042
US

IV. Provider business mailing address

182 HOLTON HILL PO BOX 473
HARDWICK VT
05843-0473
US

V. Phone/Fax

Practice location:
  • Phone: 802-584-4679
  • Fax:
Mailing address:
  • Phone: 802-498-8881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number025.0078863
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: