Provider Demographics
NPI:1710943576
Name:GATEWAY HOME DIALYSIS, INC.
Entity Type:Organization
Organization Name:GATEWAY HOME DIALYSIS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:HEANEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-733-9707
Mailing Address - Street 1:1120 N CHINOWTH ST
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-7896
Mailing Address - Country:US
Mailing Address - Phone:559-733-9707
Mailing Address - Fax:559-733-7009
Practice Address - Street 1:1120 N CHINOWTH ST
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-7896
Practice Address - Country:US
Practice Address - Phone:559-733-9707
Practice Address - Fax:559-733-7009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-21
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA240000798261QE0700X
CAFNP 18234332BD1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
No332BD1200XSuppliersDurable Medical Equipment & Medical SuppliesDialysis Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4970860001OtherCIGNA MEDICARE DMERC
CACDC02771FMedicaid
CA4970860001Medicare NSC
CACDC02771FMedicaid