Provider Demographics
NPI:1639856636
Name:GENTRY, MICHAEL JOE (LVN)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOE
Last Name:GENTRY
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 SADDLE BROOK CIR
Mailing Address - Street 2:
Mailing Address - City:HALLSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75650-7722
Mailing Address - Country:US
Mailing Address - Phone:903-203-7922
Mailing Address - Fax:
Practice Address - Street 1:5899 HWY 80 EAST
Practice Address - Street 2:BUILDING A SUITE 3
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605
Practice Address - Country:US
Practice Address - Phone:903-203-7922
Practice Address - Fax:903-660-5131
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-30
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1003219332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies