Provider Demographics
NPI:1740548767
Name:GATEWAY VISION INC
Entity type:Organization
Organization Name:GATEWAY VISION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:S
Authorized Official - Last Name:GRIMSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:904-751-4483
Mailing Address - Street 1:447 ATLANTIC BLVD
Mailing Address - Street 2:SUITE #1
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32233-4004
Mailing Address - Country:US
Mailing Address - Phone:904-247-0211
Mailing Address - Fax:
Practice Address - Street 1:1840 DUNN AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-4799
Practice Address - Country:US
Practice Address - Phone:904-751-4483
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-27
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK3748Medicare UPIN