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General NPI Number Information
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NPI Number | 1629653449
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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 | 03/12/2021
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Last Update Date | 03/12/2021
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Provider Practice Location Address
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Address Line | 132 E 5TH ST STE 103
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City | DELTA
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State | CO
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Zip | 81416-1901
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Country | US
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Telephone | 970-823-0033
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Fax |
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Provider Business Mailing Address
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Address Line | 4575 GALLEY RD STE 100D
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City | COLORADO SPRINGS
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State | CO
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Zip | 80915-2747
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Country | US
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Telephone | 970-823-0033
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/COO
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Name | KEVIN GRAVES
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Credential |
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Telephone | 970-823-0033
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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