Provider Demographics
NPI:1013289149
Name:LIFE GATE CHURCH INC
Entity Type:Organization
Organization Name:LIFE GATE CHURCH INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:C
Authorized Official - Last Name:BORSELLINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-966-9310
Mailing Address - Street 1:102 BAYNE RD
Mailing Address - Street 2:
Mailing Address - City:HASLET
Mailing Address - State:TX
Mailing Address - Zip Code:76052-4614
Mailing Address - Country:US
Mailing Address - Phone:817-675-8135
Mailing Address - Fax:
Practice Address - Street 1:102 BAYNE RD
Practice Address - Street 2:
Practice Address - City:HASLET
Practice Address - State:TX
Practice Address - Zip Code:76052-4614
Practice Address - Country:US
Practice Address - Phone:817-675-8135
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-06
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty