Healthcare Provider Details

I. General information

NPI: 1568881340
Provider Name (Legal Business Name): GATEWAY HIGH SCHOL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2014
Last Update Date: 04/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 HERNDON AVE
CLOVIS CA
93611-0569
US

IV. Provider business mailing address

1550 HERNDON AVE
CLOVIS CA
93611-0569
US

V. Phone/Fax

Practice location:
  • Phone: 559-327-1800
  • Fax:
Mailing address:
  • Phone: 559-327-1800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number100091AN
License Number StateCA

VIII. Authorized Official

Name: MR. ORLANDO GILLAM
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 559-981-2143