Provider Demographics
NPI:1275685414
Name:GATEWAY MEDICAL CENTER INC
Entity Type:Organization
Organization Name:GATEWAY MEDICAL CENTER INC
Other - Org Name:ANDERSON WALK IN CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:LOCKHART
Authorized Official - Last Name:REGUERA
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:530-365-4412
Mailing Address - Street 1:3082 MCMURRAY DR
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:CA
Mailing Address - Zip Code:96007
Mailing Address - Country:US
Mailing Address - Phone:530-365-4412
Mailing Address - Fax:530-365-5186
Practice Address - Street 1:3082 MCMURRAY DR
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:CA
Practice Address - Zip Code:96007
Practice Address - Country:US
Practice Address - Phone:530-365-4412
Practice Address - Fax:530-365-5186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5484208D00000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM53862FMedicaid
CAZZZ28215ZMedicare ID - Type UnspecifiedNHIC NUMBER
CAQ4185Medicare UPIN
CA553862Medicare ID - Type UnspecifiedRURAL HEALTH