1124783477 NPI number — GATEWAY COMMUNITY SERVICES, INC.

Table of content: (NPI 1124783477)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124783477 NPI number — GATEWAY COMMUNITY SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GATEWAY COMMUNITY SERVICES, 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:
1124783477
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
555 STOCKTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32204-2534
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-387-4661
Provider Business Mailing Address Fax Number:
904-389-8758

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2133 BROADWAY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32209-7513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-361-5010
Provider Business Practice Location Address Fax Number:
904-384-2299
Provider Enumeration Date:
11/02/2021

Additional Information

Authorized Official

Authorized Official Last Name:
VANZANDT
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
904-387-4661

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1659541654 . This is a "NPI" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1619411279 . This is a "NPI" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1316376585 . This is a "NPI" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1689252314 . This is a "NPI" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1811393499 . This is a "NPI" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1427184308 . This is a "NPI" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 060594807 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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