Basic Information
| Provider Information | |||||||||
| NPI: | 1275685414 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GATEWAY MEDICAL CENTER INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ANDERSON WALK IN CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3082 MCMURRAY DR | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 96007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5303654412 | ||||||||
| FaxNumber: | 5303655186 | ||||||||
| Practice Location | |||||||||
| Address1: | 3082 MCMURRAY DR | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 96007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5303654412 | ||||||||
| FaxNumber: | 5303655186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 02/26/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REGUERA | ||||||||
| AuthorizedOfficialFirstName: | TIFFANY | ||||||||
| AuthorizedOfficialMiddleName: | LOCKHART | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5303654412 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | F.N.P. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 208D00000X | 20A5484 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | RHM53862F | 05 | CA | MEDICAID |