MEDICARE: GULF GATE DIAGNOSTIC IMAGING

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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1104846708
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GULF GATE DIAGNOSTIC IMAGING

Provider Business Mailing Address
First Line	:	1 PUTNAM AVE
Second Line	:
City	:	ORANGE
State	:	TX
Zip	:	77630-2353
Country	:	US
Telephone Number	:	409-883-7117
Fax Number	:	409-883-7100

Provider Business Practice Location Address
First Line	:	1 PUTNAM AVE
Second Line	:
City	:	ORANGE
State	:	TX
Zip	:	77630-2353
Country	:	US
Telephone Number	:	409-883-7117
Fax Number	:	409-883-7100

Authorized Official
Title or Position	:	PRESIDENT OWNER
Name	:	MR. GUSTAVO HINCIPLE
Credential	:
Telephone Number	:	713-320-7415

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	08/22/2020

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