Provider Demographics
NPI:1073052114
Name:MISSOURI GATEWAY HEALTH, LLC
Entity Type:Organization
Organization Name:MISSOURI GATEWAY HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BRATTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-396-6412
Mailing Address - Street 1:10900 NUCKOLS RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9276
Mailing Address - Country:US
Mailing Address - Phone:804-396-6412
Mailing Address - Fax:804-482-2756
Practice Address - Street 1:10900 NUCKOLS RD
Practice Address - Street 2:STE 110
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-9276
Practice Address - Country:US
Practice Address - Phone:804-396-6412
Practice Address - Fax:804-482-2756
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALLYALIGN HEALTH, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-22
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty