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General NPI Number Information
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NPI Number | 1598044547
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Entity Type | Organization
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Legal Business Name | GATEWAY RESIDENTIAL SERVICES
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Dates
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Enumeration Date | 08/09/2011
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Last Update Date | 08/09/2011
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Provider Practice Location Address
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Address Line | 3338 ASH MESA RD
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City | DELTA
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State | CO
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Zip | 81416-8766
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Country | US
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Telephone | 970-209-8691
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Fax | 866-799-7523
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Provider Business Mailing Address
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Address Line | 3346 ASH MESA RD
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City | DELTA
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State | CO
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Zip | 81416-8766
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Country | US
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Telephone | 970-209-8691
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Fax | 866-799-7523
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Authorized Official
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Title or Position | PRESIDENT
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Name | KEVIN GRAVES
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Credential |
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Telephone | 719-641-3827
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number | 1609500
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License Number State | CO
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