Provider Demographics
NPI:1699085589
Name:GATEWAY HEALTH CENTER, LLC
Entity type:Organization
Organization Name:GATEWAY HEALTH CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:PEGUES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-648-4567
Mailing Address - Street 1:2165 HIGHWAY 78
Mailing Address - Street 2:103
Mailing Address - City:DORA
Mailing Address - State:AL
Mailing Address - Zip Code:35062
Mailing Address - Country:US
Mailing Address - Phone:205-648-4567
Mailing Address - Fax:
Practice Address - Street 1:2165 HIGHWAY 78
Practice Address - Street 2:103
Practice Address - City:DORA
Practice Address - State:AL
Practice Address - Zip Code:35062
Practice Address - Country:US
Practice Address - Phone:205-648-4567
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-14
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty