Provider Demographics
NPI:1194079582
Name:GALLEGOS, JUSTIN SHANE
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:SHANE
Last Name:GALLEGOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 CANNERY CIR
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-1442
Mailing Address - Country:US
Mailing Address - Phone:408-705-6821
Mailing Address - Fax:
Practice Address - Street 1:16400 BLOSSOM HILL RD
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-3553
Practice Address - Country:US
Practice Address - Phone:408-335-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-06
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator