MEDICARE: CITY GATE LIFE RECOVERY CENTER, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1285108746
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITY GATE LIFE RECOVERY CENTER, INC.

Provider Business Mailing Address
First Line	:	610 ASHLAND AVE
Second Line	:
City	:	BUFFALO
State	:	NY
Zip	:	14222-1309
Country	:	US
Telephone Number	:	716-510-5801
Fax Number	:

Provider Business Practice Location Address
First Line	:	610 ASHLAND AVE
Second Line	:
City	:	BUFFALO
State	:	NY
Zip	:	14222-1309
Country	:	US
Telephone Number	:	716-510-5801
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CAROL CONKLIN
Credential	:
Telephone Number	:	716-883-7713

Provider Enumeration Date	:	01/17/2019
Last Update Date	:	01/17/2019

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