Healthcare Provider Details

I. General information

NPI: 1992154314
Provider Name (Legal Business Name): GATEWAY MONITORING SPECIALITIES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 06/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9521 RIVERSIDE PKWY #338
TULSA OK
74137-7418
US

IV. Provider business mailing address

PO BOX 268977
OKLAHOMA CITY OK
73126-8977
US

V. Phone/Fax

Practice location:
  • Phone: 918-895-7680
  • Fax:
Mailing address:
  • Phone: 918-895-7680
  • Fax: 214-317-4888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204R00000X
TaxonomyElectrodiagnostic Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: TRASE MAHAN
Title or Position: MANAGER
Credential:
Phone: 214-675-0905