Basic Information
| Provider Information | |||||||||
| NPI: | 1184700205 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| 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: | 9567186259 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2007 S ZAPATA HWY | ||||||||
| Address2: | |||||||||
| City: | LAREDO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780466510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9567186259 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 06/23/2014 | ||||||||
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| AuthorizedOfficialLastName: | TREVINO | ||||||||
| AuthorizedOfficialFirstName: | MIGUEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9565233646 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | 21321 | TX | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 21321 | 01 | TX | TEXAS PHARMACY LICENSE | OTHER | 4520816 | 01 | TX | NCPDP NUMBER | OTHER | BG7629883 | 01 | TX | DEA NUMBER | OTHER |