=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750082194
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GATEWAY FOUNDATION, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2023
-----------------------------------------------------
Last Update Date | 08/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 404 N HERSHEY RD STE B
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61704-3560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-381-6538
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 55 E JACKSON BLVD
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60604-4466
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-663-1130
-----------------------------------------------------
Fax | 312-663-0504
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JEREMY KLEMANSKI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 312-663-1130
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------