MEDICARE: GALLANT MEDICAL SUPPLY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332BX2000X	Oxygen Equipment & Supplies (DME)	PENDING	CA

General Provider Information

NPI Number	:	1366597858
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GALLANT MEDICAL SUPPLY, INC.

Provider Business Mailing Address
First Line	:	27740 ENCANTO DR
Second Line	:
City	:	SUN CITY
State	:	CA
Zip	:	92586-4521
Country	:	US
Telephone Number	:	951-672-4965
Fax Number	:	951-672-4966

Provider Business Practice Location Address
First Line	:	162 N SAN JACINTO ST
Second Line	:
City	:	HEMET
State	:	CA
Zip	:	92543-4450
Country	:	US
Telephone Number	:	951-658-2505
Fax Number	:	951-658-2460

Authorized Official
Title or Position	:	CEO
Name	:	MR. YOUNG DENNIS AHN
Credential	:
Telephone Number	:	951-672-4965

Provider Enumeration Date	:	01/24/2007
Last Update Date	:	08/22/2020

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