Provider Demographics
NPI:1457897373
Name:GATEWAY TO PREVENTION AND RECOVERY SEMINOLE
Entity Type:Organization
Organization Name:GATEWAY TO PREVENTION AND RECOVERY SEMINOLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-270-1170
Mailing Address - Street 1:36609 45TH ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-8882
Mailing Address - Country:US
Mailing Address - Phone:405-273-1170
Mailing Address - Fax:405-275-4412
Practice Address - Street 1:919 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:OK
Practice Address - Zip Code:74868-3150
Practice Address - Country:US
Practice Address - Phone:405-273-1170
Practice Address - Fax:405-385-6604
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GATEWAY TO PREVENTION AND RECOVERY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100736990Medicaid