1477124790 NPI number — PATHWAYS CLINICAL PARTNERS, LLC

Table of content: (NPI 1477124790)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477124790 NPI number — PATHWAYS CLINICAL PARTNERS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PATHWAYS CLINICAL PARTNERS, 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:
1477124790
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 491500
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEESBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34749-1500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-204-5222
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1031 W MAGNOLIA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEESBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34748-5730
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-632-6228
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/07/2021

Additional Information

Authorized Official

Authorized Official Last Name:
WAGNER
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
P
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
321-204-5222

Provider Taxonomy Codes

  • Taxonomy code: 208M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 115213500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com