Healthcare Provider Details

I. General information

NPI: 1609841469
Provider Name (Legal Business Name): JAY VALENTINE GALLINGER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 12/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 NW BOISTFORT ST
CHEHALIS WA
98532-2003
US

IV. Provider business mailing address

66 NW BOISTFORT ST
CHEHALIS WA
98532-2003
US

V. Phone/Fax

Practice location:
  • Phone: 360-748-6191
  • Fax: 360-748-7208
Mailing address:
  • Phone: 360-748-6191
  • Fax: 360-748-7208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD00001920
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: