Provider Demographics
NPI:1629653449
Name:GATEWAY RESIDENTIAL SERVICES
Entity Type:Organization
Organization Name:GATEWAY RESIDENTIAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/COO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-823-0033
Mailing Address - Street 1:4575 GALLEY RD STE 100D
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80915-2747
Mailing Address - Country:US
Mailing Address - Phone:970-823-0033
Mailing Address - Fax:
Practice Address - Street 1:132 E 5TH ST STE 103
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:CO
Practice Address - Zip Code:81416-1901
Practice Address - Country:US
Practice Address - Phone:970-823-0033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GATEWAY RESIDENTIAL SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-03-12
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health