MEDICARE: GATESWAY FOUNDATION

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	315P00000X	Intellectual Disabilities Intermediate Care Facility	NH7251-7251	OK

General Provider Information

NPI Number	:	1255548368
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GATESWAY FOUNDATION

Provider Business Mailing Address
First Line	:	1217 E COLLEGE ST
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-4204
Country	:	US
Telephone Number	:	918-259-1471
Fax Number	:

Provider Business Practice Location Address
First Line	:	3836 S 117TH EAST AVE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74146-2935
Country	:	US
Telephone Number	:	918-259-1471
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. JUDI MYERS
Credential	:
Telephone Number	:	918-259-1471

Provider Enumeration Date	:	05/17/2007
Last Update Date	:	08/22/2020

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Directions to “GATESWAY FOUNDATION ” Practice Location

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