Provider Demographics
NPI:1932916699
Name:GAILLARD, PERCY DEVON JR
Entity type:Individual
Prefix:
First Name:PERCY
Middle Name:DEVON
Last Name:GAILLARD
Suffix:JR
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 1:148 CRAGGY BLUFF RD
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-8625
Mailing Address - Country:US
Mailing Address - Phone:803-231-8820
Mailing Address - Fax:
Practice Address - Street 1:1078 BOULEVARD ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-4351
Practice Address - Country:US
Practice Address - Phone:803-231-8820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-16
Last Update Date:2025-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC171400000X
SCNCCAP5030012-24NT175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No171400000XOther Service ProvidersHealth & Wellness Coach