=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366854846
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MLG PHYSICAL THERAPY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2014
-----------------------------------------------------
Last Update Date | 06/17/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1824 HIGHWAY 30 E
-----------------------------------------------------
City | DENISON
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51442-2101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-393-7000
-----------------------------------------------------
Fax | 712-393-7001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 455
-----------------------------------------------------
City | CARROLL
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51401-0455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-393-7000
-----------------------------------------------------
Fax | 712-393-7001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ PHYSICAL THERAPIST
-----------------------------------------------------
Name | MARY LOUISE GALLEGOS
-----------------------------------------------------
Credential | MPT
-----------------------------------------------------
Telephone | 317-557-2334
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------