=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417466764
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RYAN C GALLAGHER LAC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2017
-----------------------------------------------------
Last Update Date | 11/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7505 WATERS AVE STE C13
-----------------------------------------------------
City | SAVANNAH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31406-3826
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-419-4404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 208 E 32ND ST
-----------------------------------------------------
City | SAVANNAH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31401-7504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-757-6482
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 539
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------