Healthcare Provider Details

I. General information

NPI: 1063261394
Provider Name (Legal Business Name): PATHWAY ASSISTED LIVING AUTUMN RIDGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2024
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14280 W STANISLAUS AVE
KERMAN CA
93630-1594
US

IV. Provider business mailing address

14280 W STANISLAUS AVE
KERMAN CA
93630-1594
US

V. Phone/Fax

Practice location:
  • Phone: 559-642-7727
  • Fax:
Mailing address:
  • Phone: 559-642-7727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN JOHNSON
Title or Position: LICENSEE
Credential:
Phone: 661-972-4646