Provider Demographics
NPI:1194438671
Name:GALLARDOFOX, JACOB PAUL
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:PAUL
Last Name:GALLARDOFOX
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 1:44090 KARIE WAY
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-1464
Mailing Address - Country:US
Mailing Address - Phone:951-719-9055
Mailing Address - Fax:
Practice Address - Street 1:450 E SAN JACINTO AVE
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-2833
Practice Address - Country:US
Practice Address - Phone:951-443-2299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-29
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist