=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124499660
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GATEWAY FREEDOM RANCH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2015
-----------------------------------------------------
Last Update Date | 12/09/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 GLEN LAKE DR
-----------------------------------------------------
City | EUREKA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59917-9680
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-889-7996
-----------------------------------------------------
Fax | 406-889-9193
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 GLEN LAKE DR
-----------------------------------------------------
City | EUREKA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59917-9680
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-889-7996
-----------------------------------------------------
Fax | 406-889-9193
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MRS. LISA K MAREK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 406-889-7996
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------