Healthcare Provider Details

I. General information

NPI: 1891748042
Provider Name (Legal Business Name): GATEWAY FAMILY HEALTH CLINIC, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 02/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5565 HWY. 210
CROMWELL MN
55726
US

IV. Provider business mailing address

5565 HWY. 210
CROMWELL MN
55726
US

V. Phone/Fax

Practice location:
  • Phone: 218-644-3838
  • Fax: 218-644-3067
Mailing address:
  • Phone: 218-644-3838
  • Fax: 218-644-3067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number497
License Number StateMN

VIII. Authorized Official

Name: MR. WILLIAM G. PALMER
Title or Position: ADMINISTRATOR
Credential:
Phone: 218-485-4491