Provider Demographics
NPI:1407035710
Name:GATEWOOD PROSTHETICS INC
Entity Type:Organization
Organization Name:GATEWOOD PROSTHETICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER,PROSTHETIST,ORTHOTIST,PEDORTH
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:GATEWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:CPO,CPED
Authorized Official - Phone:706-596-8004
Mailing Address - Street 1:PO BOX 1623
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-1623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2515 OLD WHITTLESEY RD
Practice Address - Street 2:SUITE A
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-3020
Practice Address - Country:US
Practice Address - Phone:706-596-8004
Practice Address - Fax:706-327-3388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-02
Last Update Date:2013-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000071332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAN343442OtherWELLCARE
GA00919553AMedicaid
GA138773OtherPEACHSTATE
GA5087070001Medicare NSC