Provider Demographics
NPI:1700067931
Name:THE GATES RECOVERY FOUNDATION
Entity Type:Organization
Organization Name:THE GATES RECOVERY FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SERVICES MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:ST.ANDREW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-778-0055
Mailing Address - Street 1:2810 COLOMA ST
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-4406
Mailing Address - Country:US
Mailing Address - Phone:530-622-9500
Mailing Address - Fax:530-622-9534
Practice Address - Street 1:1864 BROADWAY
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-6018
Practice Address - Country:US
Practice Address - Phone:530-622-9500
Practice Address - Fax:530-622-9534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA090016CN324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA090016CNOtherFACILITY LICENSE NUMBER