Provider Demographics
NPI:1487409371
Name:GALLOWAY, CLAYBORN BENNETT (ATC)
Entity type:Individual
Prefix:
First Name:CLAYBORN
Middle Name:BENNETT
Last Name:GALLOWAY
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 BERRYWOOD DR STE 106A
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6517
Mailing Address - Country:US
Mailing Address - Phone:573-449-8771
Mailing Address - Fax:
Practice Address - Street 1:3301 BERRYWOOD DR STE 204
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6517
Practice Address - Country:US
Practice Address - Phone:573-449-8771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-23
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20230274702255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer