=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104318013
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOUIS GALLIA MD MEDICAL CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2018
-----------------------------------------------------
Last Update Date | 06/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 87 SCRIPPS DR #112
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-570-3088
-----------------------------------------------------
Fax | 916-570-3089
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 87 SCRIPPS DR STE #112
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-570-3088
-----------------------------------------------------
Fax | 916-570-3089
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | LOUIS JOSEPH GALLIA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 916-570-3088
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QS0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------