=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063261394
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PATHWAY ASSISTED LIVING AUTUMN RIDGE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2024
-----------------------------------------------------
Last Update Date | 08/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14280 W STANISLAUS AVE
-----------------------------------------------------
City | KERMAN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93630-1594
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-642-7727
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14280 W STANISLAUS AVE
-----------------------------------------------------
City | KERMAN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93630-1594
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-642-7727
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSEE
-----------------------------------------------------
Name | JONATHAN JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 661-972-4646
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------