Provider Demographics
NPI:1124499660
Name:GATEWAY FREEDOM RANCH
Entity type:Organization
Organization Name:GATEWAY FREEDOM RANCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:K
Authorized Official - Last Name:MAREK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-889-7996
Mailing Address - Street 1:111 GLEN LAKE DR
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MT
Mailing Address - Zip Code:59917-9680
Mailing Address - Country:US
Mailing Address - Phone:406-889-7996
Mailing Address - Fax:406-889-9193
Practice Address - Street 1:111 GLEN LAKE DR
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:MT
Practice Address - Zip Code:59917-9680
Practice Address - Country:US
Practice Address - Phone:406-889-7996
Practice Address - Fax:406-889-9193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-09
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness