MEDICARE: GULF COAST PHYSICAL MEDICINE PLLC

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	111NS0005X	Sports Physician Chiropractor
2	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1699183145
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GULF COAST PHYSICAL MEDICINE PLLC

Provider Business Mailing Address
First Line	:	8800 KATY FWY STE 105
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77024-1645
Country	:	US
Telephone Number	:	832-831-8656
Fax Number	:	832-831-8674

Provider Business Practice Location Address
First Line	:	8800 KATY FWY
Second Line	:	SUITE 105
City	:	HOUSTON
State	:	TX
Zip	:	77024-1633
Country	:	US
Telephone Number	:	832-831-8656
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KANON FRANK OSWALD
Credential	:	D.C.
Telephone Number	:	281-948-4111

Provider Enumeration Date	:	07/29/2014
Last Update Date	:	01/06/2015

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