Healthcare Provider Details

I. General information

NPI: 1669025672
Provider Name (Legal Business Name): GATEWAY FOUNDATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2019
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25480 W CEDAR CREST LN BLDG A
LAKE VILLA IL
60046-9744
US

IV. Provider business mailing address

55 E JACKSON BLVD STE 1500
CHICAGO IL
60604-4184
US

V. Phone/Fax

Practice location:
  • Phone: 847-356-8205
  • Fax: 847-356-3033
Mailing address:
  • Phone: 312-663-1130
  • Fax: 312-663-0504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: RENEE ENNIS MCGEE
Title or Position: MANAGER
Credential:
Phone: 678-445-4833