=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457088858
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GATE MEDICAL SUPPLY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2022
-----------------------------------------------------
Last Update Date | 08/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1685 E MAIN ST STE 202-A
-----------------------------------------------------
City | EL CAJON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92021-5225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-844-8730
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 960 E CHASE AVE APT G
-----------------------------------------------------
City | EL CAJON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92020-7666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-737-6219
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. GLENN ALLEN THORNTON JR.
-----------------------------------------------------
Credential | RCP
-----------------------------------------------------
Telephone | 619-737-6219
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BD1200X
-----------------------------------------------------
Taxonomy Name | Dialysis Equipment & Supplies (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332BX2000X
-----------------------------------------------------
Taxonomy Name | Oxygen Equipment & Supplies (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 332BP3500X
-----------------------------------------------------
Taxonomy Name | Parenteral & Enteral Nutrition Supplies (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------