=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588171581
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK GALLANT DC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2017
-----------------------------------------------------
Last Update Date | 12/29/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2117 49TH ST N
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33710-5233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-327-0721
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4920 5TH AVE N
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33710-7302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MGR
-----------------------------------------------------
Name | DR. MARK GALLANT
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 727-333-1250
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 10796
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------