Basic Information
| Provider Information | |||||||||
| NPI: | 1558911305 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GALLEGOS | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RADT-I | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7466 GUTHRIE ST APT B | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924104376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3239215877 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3316 W BEVERLY BLVD | ||||||||
| Address2: | |||||||||
| City: | MONTEBELLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906401537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237224529 | ||||||||
| FaxNumber: | 3237224450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2019 | ||||||||
| LastUpdateDate: | 01/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 01/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | R1361770819 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.