1912271461 NPI number — GATEWAY BEHAHVIORAL HEALTH SERVICES

Table of content: (NPI 1912271461)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912271461 NPI number — GATEWAY BEHAHVIORAL HEALTH SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GATEWAY BEHAHVIORAL HEALTH SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GLYNN PINEHAVEN GROUP HOME
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912271461
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
727 PINE HAVEN CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRUNSWICK
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31525-9567
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 COASTAL VILLAGE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRUNSWICK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31520-1974
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-554-8510
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/01/2012

Additional Information

Authorized Official

Authorized Official Last Name:
SKINNER
Authorized Official First Name:
RACHEL
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF REIMBURSEMENT
Authorized Official Telephone Number:
912-554-8498

Provider Taxonomy Codes

  • Taxonomy code: 320900000X , with the licence number:  063-01-035-2 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000622553BI , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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