MEDICARE: PATHWAYS COMMUNITY CLINIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320800000X	Mental Illness Community Based Residential Treatment Facility
2	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1194611665
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PATHWAYS COMMUNITY CLINIC LLC

Provider Business Mailing Address
First Line	:	1634 E MINNESOTA ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46203-2842
Country	:	US
Telephone Number	:	317-993-2473
Fax Number	:

Provider Business Practice Location Address
First Line	:	1634 E MINNESOTA ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46203-2842
Country	:	US
Telephone Number	:	317-993-2473
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	ANGEL BUMPHUS
Credential	:	MBA
Telephone Number	:	317-993-2473

Provider Enumeration Date	:	06/13/2025
Last Update Date	:	06/13/2025

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