1174851042 NPI number — PATHWAYS OF MAINE, LLC

Table of content: (NPI 1174851042)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174851042 NPI number — PATHWAYS OF MAINE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PATHWAYS OF MAINE, LLC
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:
Provider Other Organization Name Type Code:
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:
1174851042
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10304 SPOTSYLVANIA AVE
Provider Second Line Business Mailing Address:
3RD FLOOR
Provider Business Mailing Address City Name:
FREDERICKSBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22408-8602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-710-2800
Provider Business Mailing Address Fax Number:
540-710-7447

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
62 PEGASUS ST
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
BRUNSWICK
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04011-5028
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-373-0620
Provider Business Practice Location Address Fax Number:
207-373-0628
Provider Enumeration Date:
12/03/2009

Additional Information

Authorized Official

Authorized Official Last Name:
ZENGA
Authorized Official First Name:
NICOLE
Authorized Official Middle Name:
T
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
207-373-0620

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  392123 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 191700000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com