1407035710 NPI number — GATEWOOD PROSTHETICS INC

Table of content: (NPI 1407035710)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407035710 NPI number — GATEWOOD PROSTHETICS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GATEWOOD PROSTHETICS 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:
1407035710
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1623
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORTSON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31808-1623
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:
2515 OLD WHITTLESEY RD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31909-3020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-596-8004
Provider Business Practice Location Address Fax Number:
706-327-3388
Provider Enumeration Date:
11/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GATEWOOD
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER,PROSTHETIST,ORTHOTIST,PEDORTH
Authorized Official Telephone Number:
706-596-8004

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  000071 , 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: N343442 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 00919553A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 138773 . This is a "PEACHSTATE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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