=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750681821
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GATEWAY COMMUNITY SUPPORT SYSTEMS,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2010
-----------------------------------------------------
Last Update Date | 12/13/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 28 SALLIOTTE RD
-----------------------------------------------------
City | ECORSE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48229-1752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-610-2217
-----------------------------------------------------
Fax | 734-818-1438
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28 SALLIOTTE RD
-----------------------------------------------------
City | ECORSE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48229-1752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-610-2217
-----------------------------------------------------
Fax | 734-818-1438
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. APRIL EXANDRA CAIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 734-558-6788
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------