1063771798 NPI number — GORDIAN MEDICAL II, INC.

Table of content: (NPI 1063771798)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063771798 NPI number — GORDIAN MEDICAL II, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GORDIAN MEDICAL II, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063771798
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
750 THE CITY DR S STE 225
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92868-4976
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-566-0200
Provider Business Mailing Address Fax Number:
877-380-8282

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5834 LOUETTA RD
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
SPRING
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77379-7884
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-205-7091
Provider Business Practice Location Address Fax Number:
281-205-7093
Provider Enumeration Date:
05/15/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BOWMAN
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
714-566-0200

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  28042 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10026638400 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1063771798 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 203002585 . This is a "DME LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 3125558 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9000143125 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 103822 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1063771798 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1063771798 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1063771798 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2149270 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 58080708 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: DME000833 . This is a "DME LICENSE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 08547 . This is a "DME LICENSE" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 09722542 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1063771798 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1703530 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 300003799 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6709192 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 69001683A . This is a "DME LICENSE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: Q030405 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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