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General NPI Number Information
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NPI Number | 1740783679
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Entity Type | Organization
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Legal Business Name | GATEWAY RESIDENTIAL SUPPORTS
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Dates
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Enumeration Date | 03/16/2018
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Last Update Date | 03/16/2018
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Provider Practice Location Address
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Address Line | 4321 SOUTHERN PKWY
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City | LOUISVILLE
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State | KY
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Zip | 40214-1583
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Country | US
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Telephone | 502-395-1672
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Fax |
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Provider Business Mailing Address
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Address Line | 4321 SOUTHERN PKWY
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City | LOUISVILLE
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State | KY
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Zip | 40214-1583
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | STACEY MILLIGAN
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Credential |
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Telephone | 502-223-2488
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number |
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License Number State |
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