MEDICARE: SACRED PATH INDIGENOUS WELLNESS CENTER

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1255115077
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SACRED PATH INDIGENOUS WELLNESS CENTER

Provider Business Mailing Address
First Line	:	2232 KINGSBRIDGE CT
Second Line	:
City	:	SAN DIMAS
State	:	CA
Zip	:	91773-3757
Country	:	US
Telephone Number	:	626-290-1505
Fax Number	:

Provider Business Practice Location Address
First Line	:	2232 KINGSBRIDGE CT
Second Line	:
City	:	SAN DIMAS
State	:	CA
Zip	:	91773-3757
Country	:	US
Telephone Number	:	626-290-1505
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	CARRIE JOHNSON
Credential	:	PH.D.
Telephone Number	:	626-290-1505

Provider Enumeration Date	:	08/22/2023
Last Update Date	:	06/03/2026

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