Healthcare Provider Details

I. General information

NPI: 1083812259
Provider Name (Legal Business Name): GULFCOAST WELLNESS MANAGEMT GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 11/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2404 CAROLINE ST
HOUSTON TX
77004-1016
US

IV. Provider business mailing address

2404 CAROLINE ST
HOUSTON TX
77004-1016
US

V. Phone/Fax

Practice location:
  • Phone: 713-524-4803
  • Fax: 713-524-4801
Mailing address:
  • Phone: 713-524-4803
  • Fax: 713-524-4801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberAM0871776
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG7943
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG7943
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberG7943
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberG7943
License Number StateTX
# 6
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberF006483
License Number StateTX

VIII. Authorized Official

Name: LAMONT RATCLIFF
Title or Position: DIRECTOR
Credential:
Phone: 713-524-4803