MEDICARE: PATHWAYS OF LIFE 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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1265284665
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PATHWAYS OF LIFE LLC

Provider Business Mailing Address
First Line	:	3817 RUSSET FALLS ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-7644
Country	:	US
Telephone Number	:	909-991-5571
Fax Number	:

Provider Business Practice Location Address
First Line	:	3817 RUSSET FALLS ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-7644
Country	:	US
Telephone Number	:	909-991-5571
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BRIAN SIMMONS
Credential	:
Telephone Number	:	909-991-5571

Provider Enumeration Date	:	04/01/2024
Last Update Date	:	07/17/2024

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Directions to “PATHWAYS OF LIFE LLC ” Practice Location

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