Basic Information
| Provider Information | |||||||||
| NPI: | 1154590610 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GATEWAY COMMUNITY HEALTH CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2007 S ZAPATA HWY | ||||||||
| Address2: | |||||||||
| City: | LAREDO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780466510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9565233642 | ||||||||
| FaxNumber: | 9567186294 | ||||||||
| Practice Location | |||||||||
| Address1: | 2007 S ZAPATA HWY | ||||||||
| Address2: | |||||||||
| City: | LAREDO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780466510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9565233642 | ||||||||
| FaxNumber: | 9567186294 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2008 | ||||||||
| LastUpdateDate: | 10/21/2009 | ||||||||
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| AuthorizedOfficialLastName: | TREVINO | ||||||||
| AuthorizedOfficialFirstName: | MIGUEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9565233642 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GATEWAY COMMUNITY HEALTH CENTER, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 081896502 | 05 | TX | MEDICAID |