Provider Demographics
NPI:1215298898
Name:456678LIFE GATE
Entity type:Organization
Organization Name:456678LIFE GATE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BILL
Authorized Official - Middle Name:
Authorized Official - Last Name:BATEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-902-3770
Mailing Address - Street 1:10922 E 39TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-2703
Mailing Address - Country:US
Mailing Address - Phone:918-378-6912
Mailing Address - Fax:
Practice Address - Street 1:10922 E 39TH STREET SOUTH
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-2703
Practice Address - Country:US
Practice Address - Phone:918-378-6912
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-31
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization