1104130632 NPI number — GATEWAY COMMUNITY INITIATIVE, INC

Table of content: (NPI 1104130632)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104130632 NPI number — GATEWAY COMMUNITY INITIATIVE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GATEWAY COMMUNITY INITIATIVE, INC
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:
Provider Other Organization Name Type Code:
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:
1104130632
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/26/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2510 GARDEN HILL DR
Provider Second Line Business Mailing Address:
303
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27614-6899
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-896-4380
Provider Business Mailing Address Fax Number:
800-991-0902

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 WINDEL DR
Provider Second Line Business Practice Location Address:
205
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27609-4475
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-896-4380
Provider Business Practice Location Address Fax Number:
800-991-0902
Provider Enumeration Date:
07/26/2010

Additional Information

Authorized Official

Authorized Official Last Name:
PARKER
Authorized Official First Name:
ANGELA
Authorized Official Middle Name:
S
Authorized Official Title or Position:
CLINICAL DIRECTOR
Authorized Official Telephone Number:
919-896-4380

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 6112104 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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