Healthcare Provider Details

I. General information

NPI: 1306291158
Provider Name (Legal Business Name): ENLIGHTENED PATH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2016
Last Update Date: 04/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5544 MYRON CIR
LAS VEGAS NV
89142-1123
US

IV. Provider business mailing address

5544 MYRON CIR
LAS VEGAS NV
89142-1123
US

V. Phone/Fax

Practice location:
  • Phone: 505-814-9745
  • Fax:
Mailing address:
  • Phone: 505-814-9745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateNV

VIII. Authorized Official

Name: MR. YAUNCAY J LUCAS
Title or Position: OWNER CFO/CEO
Credential:
Phone: 505-814-9745