Basic Information
| Provider Information | |||||||||
| NPI: | 1467809244 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GATEWAY MOUNTAIN CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 995 | ||||||||
| Address2: | |||||||||
| City: | SODA SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 957280995 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 10038 MEADOW WAY UNIT A | ||||||||
| Address2: | |||||||||
| City: | TRUCKEE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961614974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5304262110 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2016 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | MAYFIELD | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5302056245 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOCIAL AND ENVIRONMENTAL ENTREPRENEURS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | 90265 | CA | N | Agencies | Case Management | 251S00000X | 90265 | CA | Y | Agencies | Community/Behavioral Health |
No ID Information.