Basic Information
| Provider Information | |||||||||
| NPI: | 1851420079 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GATEWAYS FCTP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 621 S VIRGIL AVE | ||||||||
| Address2: | # 300 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900054000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2133685400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1891 EFFIE ST | ||||||||
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| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900261711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3236442000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 08/15/2017 | ||||||||
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| AuthorizedOfficialLastName: | WONG | ||||||||
| AuthorizedOfficialFirstName: | PHIL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3236442000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 930000058 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.