Provider Demographics
NPI:1558179523
Name:GALLUS OUTPATIENT SERVICES OF ARIZONA LLC
Entity type:Organization
Organization Name:GALLUS OUTPATIENT SERVICES OF ARIZONA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-501-2222
Mailing Address - Street 1:7200 E HAMPDEN AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80224-3054
Mailing Address - Country:US
Mailing Address - Phone:720-501-2222
Mailing Address - Fax:
Practice Address - Street 1:2600 N 44TH ST STE B102
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-1587
Practice Address - Country:US
Practice Address - Phone:720-501-2220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-23
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty