Healthcare Provider Details

I. General information

NPI: 1710943576
Provider Name (Legal Business Name): GATEWAY HOME DIALYSIS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 12/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 N CHINOWTH ST
VISALIA CA
93291-7896
US

IV. Provider business mailing address

1120 N CHINOWTH ST
VISALIA CA
93291-7896
US

V. Phone/Fax

Practice location:
  • Phone: 559-733-9707
  • Fax: 559-733-7009
Mailing address:
  • Phone: 559-733-9707
  • Fax: 559-733-7009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number240000798
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332BD1200X
TaxonomyDialysis Equipment & Supplies (DME)
License NumberFNP 18234
License Number StateCA

VIII. Authorized Official

Name: SARAH HEANEY
Title or Position: ADMINISTRATOR
Credential:
Phone: 559-733-9707