Healthcare Provider Details

I. General information

NPI: 1598044547
Provider Name (Legal Business Name): GATEWAY RESIDENTIAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2011
Last Update Date: 08/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3338 ASH MESA RD
DELTA CO
81416-8766
US

IV. Provider business mailing address

3346 ASH MESA RD
DELTA CO
81416-8766
US

V. Phone/Fax

Practice location:
  • Phone: 970-209-8691
  • Fax: 866-799-7523
Mailing address:
  • Phone: 970-209-8691
  • Fax: 866-799-7523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number1609500
License Number StateCO

VIII. Authorized Official

Name: KEVIN GRAVES
Title or Position: PRESIDENT
Credential:
Phone: 719-641-3827