=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073972709
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYLE GALLAGHER L.A.T.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2016
-----------------------------------------------------
Last Update Date | 02/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 231 GARFIELD DR
-----------------------------------------------------
City | GRAND JUNCTION
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81503-2972
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-433-2667
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 231 GARFIELD DR
-----------------------------------------------------
City | GRAND JUNCTION
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81503-2972
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-433-2667
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 1411
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------