Provider Demographics
NPI:1871146027
Name:GALOS, COLEBURN JAMES DAVID
Entity type:Individual
Prefix:
First Name:COLEBURN
Middle Name:JAMES DAVID
Last Name:GALOS
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 1:2130 E 4TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3818
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1120 W LA VETA AVE STE 660&470
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4231
Practice Address - Country:US
Practice Address - Phone:714-509-8210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-17
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker