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General NPI Number Information
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NPI Number | 1154551802
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Entity Type | Organization
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Legal Business Name | GATEWAY WELLNESS CENTER, LLC
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Dates
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Enumeration Date | 07/15/2009
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Last Update Date | 07/15/2009
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Provider Practice Location Address
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Address Line | 112 JEFFERSON AVE SUITE 201
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City | COLUMBUS
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State | OH
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Zip | 43215-1861
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Country | US
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Telephone | 614-453-1065
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Fax | 614-453-1078
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Provider Business Mailing Address
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Address Line | 112 JEFFERSON AVE SUITE 201
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City | COLUMBUS
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State | OH
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Zip | 43215-1861
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Country | US
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Telephone | 614-453-1065
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Fax | 614-453-1078
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | MARK ANTHONY WHITE
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Credential | MD
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Telephone | 614-453-1065
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 35072866
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License Number State | OH
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