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General NPI Number Information
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NPI Number | 1376717769
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Entity Type | Organization
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Legal Business Name | PATHWAY SERVICES UNLIMITED INC
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Dates
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Enumeration Date | 04/16/2008
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Last Update Date | 03/11/2016
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Provider Practice Location Address
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Address Line | 1905 W MORTON AVE
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City | JACKSONVILLE
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State | IL
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Zip | 62650-2620
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Country | US
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Telephone | 217-479-2300
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Fax | 217-479-2305
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Provider Business Mailing Address
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Address Line | 1905 W MORTON AVE
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City | JACKSONVILLE
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State | IL
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Zip | 62650-2620
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Country | US
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Telephone | 217-479-2300
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Fax | 217-479-2305
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. STEPHEN R BRUNDAGE
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Credential |
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Telephone | 217-479-2300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number | 91S144
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number | 91S144
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License Number State | IL
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