1508092776 NPI number — FSL PATHWAYS

Table of content: (NPI 1508092776)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508092776 NPI number — FSL PATHWAYS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FSL PATHWAYS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
AGL - CANYON
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508092776
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/26/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1201 E THOMAS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85014-5734
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-285-0505
Provider Business Mailing Address Fax Number:
602-285-1838

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13629 N 21ST DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85029-1502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-285-0505
Provider Business Practice Location Address Fax Number:
602-285-1838
Provider Enumeration Date:
06/02/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
INIGUEZ
Authorized Official First Name:
ANNETTE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
EXECUTIVE ASSISTANT
Authorized Official Telephone Number:
602-285-0505

Provider Taxonomy Codes

  • Taxonomy code: 320800000X , with the licence number:  BH3294 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 433075 . This is a "AHCCCS ID #" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: BH3294 . This is a "BEHAVIORAL HEALTH" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".