MEDICARE: GATEWAY HOME DIALYSIS, 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	332BD1200X	Dialysis Equipment & Supplies (DME)	FNP 18234	CA
2	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center	240000798	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4970860001	OTHER	CA	CIGNA MEDICARE DMERC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710943576
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GATEWAY HOME DIALYSIS, INC.

Provider Business Mailing Address
First Line	:	1120 N CHINOWTH ST
Second Line	:
City	:	VISALIA
State	:	CA
Zip	:	93291-7896
Country	:	US
Telephone Number	:	559-733-9707
Fax Number	:	559-733-7009

Provider Business Practice Location Address
First Line	:	1120 N CHINOWTH ST
Second Line	:
City	:	VISALIA
State	:	CA
Zip	:	93291-7896
Country	:	US
Telephone Number	:	559-733-9707
Fax Number	:	559-733-7009

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	SARAH HEANEY
Credential	:
Telephone Number	:	559-733-9707

Provider Enumeration Date	:	04/21/2006
Last Update Date	:	12/30/2009

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