MEDICARE: GATEWAY WELLNESS LLC

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1912743899
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GATEWAY WELLNESS LLC

Provider Business Mailing Address
First Line	:	3026 LOGAN AVE N
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55411-1256
Country	:	US
Telephone Number	:	612-458-4191
Fax Number	:

Provider Business Practice Location Address
First Line	:	3026 LOGAN AVE N
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55411-1256
Country	:	US
Telephone Number	:	612-458-4191
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SUHABE H JAMA
Credential	:
Telephone Number	:	612-458-4191

Provider Enumeration Date	:	07/01/2024
Last Update Date	:	07/01/2024

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Directions to “GATEWAY WELLNESS LLC ” Practice Location

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