Healthcare Provider Details

I. General information

NPI: 1174464267
Provider Name (Legal Business Name): PATHWAY RESIDENTIAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2026
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 DUCHAINE DR
GORHAM ME
04038-2085
US

IV. Provider business mailing address

27 DUCHAINE DR
GORHAM ME
04038-2085
US

V. Phone/Fax

Practice location:
  • Phone: 405-861-4998
  • Fax:
Mailing address:
  • Phone: 405-961-4998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MIKE MUGISHA
Title or Position: MANAGING MEMBER
Credential:
Phone: 405-861-4998