MEDICARE: KINGSGATE MEDICAL SUPPLY, LLC

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	332B00000X	Durable Medical Equipment & Medical Supplies	1000013	TX

General Provider Information

NPI Number	:	1538301080
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KINGSGATE MEDICAL SUPPLY, LLC

Provider Business Mailing Address
First Line	:	1117 W PIONEER PKWY
Second Line	:	SUITE 120
City	:	ARLINGTON
State	:	TX
Zip	:	76013-6395
Country	:	US
Telephone Number	:	817-275-1950
Fax Number	:	817-275-1895

Provider Business Practice Location Address
First Line	:	1117 W PIONEER PKWY
Second Line	:	SUITE 120
City	:	ARLINGTON
State	:	TX
Zip	:	76013-6395
Country	:	US
Telephone Number	:	817-275-1950
Fax Number	:	817-275-1895

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	MR. ABIODUN A BADEJO
Credential	:
Telephone Number	:	817-275-1950

Provider Enumeration Date	:	03/30/2009
Last Update Date	:	03/30/2009

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