Healthcare Provider Details

I. General information

NPI: 1154551802
Provider Name (Legal Business Name): GATEWAY WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2009
Last Update Date: 07/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 JEFFERSON AVE SUITE 201
COLUMBUS OH
43215-1861
US

IV. Provider business mailing address

112 JEFFERSON AVE SUITE 201
COLUMBUS OH
43215-1861
US

V. Phone/Fax

Practice location:
  • Phone: 614-453-1065
  • Fax: 614-453-1078
Mailing address:
  • Phone: 614-453-1065
  • Fax: 614-453-1078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number35072866
License Number StateOH

VIII. Authorized Official

Name: MARK ANTHONY WHITE
Title or Position: PRESIDENT/OWNER
Credential: MD
Phone: 614-453-1065