MEDICARE: COMPASSION PATHWAY BEHAVIORAL HEALTH 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

General Provider Information

NPI Number	:	1497406425
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMPASSION PATHWAY BEHAVIORAL HEALTH LLC

Provider Business Mailing Address
First Line	:	5410 WHITE LOTUS WAY
Second Line	:
City	:	ELK GROVE
State	:	CA
Zip	:	95757-4354
Country	:	US
Telephone Number	:	916-870-9676
Fax Number	:

Provider Business Practice Location Address
First Line	:	4229 TOYAN DR
Second Line	:
City	:	DIAMOND SPRINGS
State	:	CA
Zip	:	95619-9702
Country	:	US
Telephone Number	:	916-870-9676
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MR. IFEANYI EZEANI
Credential	:
Telephone Number	:	916-870-9676

Provider Enumeration Date	:	01/11/2022
Last Update Date	:	03/03/2022

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