Provider Demographics
NPI:1003839978
Name:GULF BIOMECHANICAL LAB LLC
Entity Type:Organization
Organization Name:GULF BIOMECHANICAL LAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:E
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:LPO
Authorized Official - Phone:210-495-3399
Mailing Address - Street 1:1500 N SAINT MARYS ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78215-1412
Mailing Address - Country:US
Mailing Address - Phone:210-495-3399
Mailing Address - Fax:210-495-3393
Practice Address - Street 1:155 UPTOWN AVE
Practice Address - Street 2:STE B
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78520-7567
Practice Address - Country:US
Practice Address - Phone:956-541-8419
Practice Address - Fax:956-541-1298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
TX101032335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX091646201Medicaid
TX530217OtherBLUE CROSS O&P
TX017056501Medicaid
TX0553300002Medicare NSC