Healthcare Provider Details

I. General information

NPI: 1902930266
Provider Name (Legal Business Name): BARBARA GATES MITCHEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 04/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 SHULT DR SUITE 208
COLUMBUS TX
78934-3009
US

IV. Provider business mailing address

PO BOX 627
COLUMBUS TX
78934-0627
US

V. Phone/Fax

Practice location:
  • Phone: 979-733-9500
  • Fax: 979-733-9501
Mailing address:
  • Phone: 979-733-9500
  • Fax: 979-733-9501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number1197
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number1197
License Number StateTX

VIII. Authorized Official

Name: DR. BARBARA GATES MITCHEM
Title or Position: OWNER
Credential: D.C., L.O.
Phone: 979-733-9500