Provider Demographics
NPI:1093771883
Name:GATEWAY REHABILITATION COMPANY, LLC
Entity Type:Organization
Organization Name:GATEWAY REHABILITATION COMPANY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:
Authorized Official - Credentials:LPT
Authorized Official - Phone:618-258-9093
Mailing Address - Street 1:935 EAST AIRLINE DR
Mailing Address - Street 2:
Mailing Address - City:EAST ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62024
Mailing Address - Country:US
Mailing Address - Phone:618-258-9093
Mailing Address - Fax:618-258-9097
Practice Address - Street 1:935 EAST AIRLINE DR
Practice Address - Street 2:
Practice Address - City:EAST ALTON
Practice Address - State:IL
Practice Address - Zip Code:62024
Practice Address - Country:US
Practice Address - Phone:618-258-9093
Practice Address - Fax:618-258-9097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-21
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL577130Medicare ID - Type UnspecifiedGROUP #