MEDICARE: EARL DARRELL GALLOW JR. CPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171400000X	Health & Wellness Coach		FL
2	2255A2300X	Athletic Trainer		CO

General Provider Information

NPI Number	:	1235959172
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EARL DARRELL GALLOW JR. CPT

Provider Business Mailing Address
First Line	:	18441 GERANIUM RD
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33967-3322
Country	:	US
Telephone Number	:	719-505-0955
Fax Number	:

Provider Business Practice Location Address
First Line	:	19150 ACORN RD STE 103
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33967-3657
Country	:	US
Telephone Number	:	239-267-3133
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/15/2024
Last Update Date	:	10/15/2024

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