Healthcare Provider Details

I. General information

NPI: 1346677242
Provider Name (Legal Business Name): GATEWAY PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2013
Last Update Date: 10/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4566 E INVERNESS AVE SUITE 103
MESA AZ
85206-4633
US

IV. Provider business mailing address

4566 E INVERNESS AVE SUITE 103
MESA AZ
85206-4633
US

V. Phone/Fax

Practice location:
  • Phone: 480-813-9191
  • Fax: 480-813-0025
Mailing address:
  • Phone: 480-813-9191
  • Fax: 480-813-0025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number8527AZ
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number305R00000X
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number305R00000X
License Number StateAZ

VIII. Authorized Official

Name: STEVEN KEMPTON
Title or Position: OWNER
Credential: PT, DPT
Phone: 480-813-9191