Provider Demographics
NPI:1831134592
Name:STARGATE MOBILITY
Entity Type:Organization
Organization Name:STARGATE MOBILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFERIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:DODGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-598-2953
Mailing Address - Street 1:5688 ROUTE 219
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:PA
Mailing Address - Zip Code:15823-1818
Mailing Address - Country:US
Mailing Address - Phone:814-265-0838
Mailing Address - Fax:814-265-2167
Practice Address - Street 1:5688 ROUTE 219
Practice Address - Street 2:
Practice Address - City:BROCKPORT
Practice Address - State:PA
Practice Address - Zip Code:15823-1818
Practice Address - Country:US
Practice Address - Phone:814-265-0838
Practice Address - Fax:814-265-2167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies