MEDICARE: LIFE GATEWAY

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	103TC2200X	Clinical Child & Adolescent Psychologist		NV

General Provider Information

NPI Number	:	1710246921
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE GATEWAY

Provider Business Mailing Address
First Line	:	3605 MOUNTAIN CREST ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-7864
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2128 PINK CORAL DR
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-0985
Country	:	US
Telephone Number	:	702-234-9822
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	CYNTHIA EWELL
Credential	:
Telephone Number	:	702-752-9274

Provider Enumeration Date	:	05/08/2012
Last Update Date	:	05/08/2012

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Directions to “LIFE GATEWAY ” Practice Location

Language	Start Address	Practice Location

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