=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003368994
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PATH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2016
-----------------------------------------------------
Last Update Date | 11/19/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 290 N 2ND STREET
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95112-1231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-320-9035
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 290 N 2ND STREET
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-320-9035
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SR. DIRECTOR OF COMPLIANCE & QA
-----------------------------------------------------
Name | LA KEISHIA NICOLE CHILDERS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 323-644-2224
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number | 1003223124
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------