Healthcare Provider Details

I. General information

NPI: 1578011565
Provider Name (Legal Business Name): GATEWAY ADDICTION CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2016
Last Update Date: 10/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 BOULDER ST
PAWNEE OK
74058-4028
US

IV. Provider business mailing address

PO BOX 334
BIXBY OK
74008-0334
US

V. Phone/Fax

Practice location:
  • Phone: 918-771-0437
  • Fax:
Mailing address:
  • Phone: 918-771-0437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. ALBERT F SANCHEZ
Title or Position: CEO
Credential:
Phone: 479-263-2690