Basic Information
| Provider Information | |||||||||
| NPI: | 1922201201 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GATEWAY COMMUNITY HEALTH CENTER, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GATEWAY COMMUNITY HEALTH CENTER, INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1515 PAPPAS ST | ||||||||
| Address2: | |||||||||
| City: | LAREDO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9567958100 | ||||||||
| FaxNumber: | 9567958135 | ||||||||
| Practice Location | |||||||||
| Address1: | 1515 PAPPAS ST | ||||||||
| Address2: | |||||||||
| City: | LAREDO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9567958100 | ||||||||
| FaxNumber: | 9567958135 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 02/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | TREVINO | ||||||||
| AuthorizedOfficialFirstName: | MIGUEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9567958100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
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 | G60097-01 | 01 | TX | DELTA DENTAL | OTHER |