1649536640 NPI number — PRIMARY PATHWAYS, LLC

Table of content: (NPI 1649536640)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649536640 NPI number — PRIMARY PATHWAYS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIMARY PATHWAYS, 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:
6
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:
1649536640
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/18/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3904 N DRUID HILLS RD # 214
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30033-3105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-500-5508
Provider Business Mailing Address Fax Number:
404-597-4050

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1258 CONCORD RD SE STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SMYRNA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30080-4302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-500-5508
Provider Business Practice Location Address Fax Number:
404-597-4050
Provider Enumeration Date:
04/04/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MURRY
Authorized Official First Name:
JACQUELINE
Authorized Official Middle Name:
D
Authorized Official Title or Position:
AGENT
Authorized Official Telephone Number:
770-500-5508

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SLP005791 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 674689092D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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