Provider Demographics
NPI:1184725095
Name:GALLEGOS, KENNETH L (CSFA/ CST)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:L
Last Name:GALLEGOS
Suffix:
Gender:M
Credentials:CSFA/ CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 471973
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80047-1973
Mailing Address - Country:US
Mailing Address - Phone:303-525-1698
Mailing Address - Fax:303-827-3401
Practice Address - Street 1:6903 S PICADILLY ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80016-2341
Practice Address - Country:US
Practice Address - Phone:303-525-1698
Practice Address - Fax:720-500-2142
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO178983246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant