Provider Demographics
NPI:1265977862
Name:GATEWAY WELLMESS CENTER
Entity type:Organization
Organization Name:GATEWAY WELLMESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEER ADVOCATE
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-644-2040
Mailing Address - Street 1:433 N HOOVER ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-2306
Mailing Address - Country:US
Mailing Address - Phone:323-644-2040
Mailing Address - Fax:
Practice Address - Street 1:433 N HOOVER ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-2306
Practice Address - Country:US
Practice Address - Phone:323-644-2040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-05
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1720151137283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital