Healthcare Provider Details

I. General information

NPI: 1306946777
Provider Name (Legal Business Name): GATEWAY REHABILITATION TAYLORVILLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 04/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301-305 S WEBSTER
TAYLORVILLE IL
62568
US

IV. Provider business mailing address

935 E AIRLINE DR
EAST ALTON IL
62024
US

V. Phone/Fax

Practice location:
  • Phone: 618-258-9093
  • Fax: 618-258-9097
Mailing address:
  • Phone: 618-258-9093
  • Fax: 618-258-9097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. LARRY D HAWKINS
Title or Position: PARTNER
Credential: LPT
Phone: 618-258-9093