Healthcare Provider Details

I. General information

NPI: 1609492693
Provider Name (Legal Business Name): GATEWAY MEDSPA LLC DBA DANA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2020
Last Update Date: 12/14/2022
Certification Date: 01/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 CEDRIC ST
LEESBURG GA
31763-5027
US

IV. Provider business mailing address

165 CEDRIC ST
LEESBURG GA
31763-5027
US

V. Phone/Fax

Practice location:
  • Phone: 229-405-1900
  • Fax: 229-304-4486
Mailing address:
  • Phone: 229-405-1900
  • Fax: 229-304-4486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. TOKELA S HUSTON
Title or Position: OWNER
Credential:
Phone: 229-854-0146