MEDICARE: MINNESOTA PATHWAY WELLNESS INC

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	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1922816750
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINNESOTA PATHWAY WELLNESS INC

Provider Business Mailing Address
First Line	:	20731 HOLYOKE AVE
Second Line	:
City	:	LAKEVILLE
State	:	MN
Zip	:	55044-9825
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	20731 HOLYOKE AVE
Second Line	:
City	:	LAKEVILLE
State	:	MN
Zip	:	55044-9825
Country	:	US
Telephone Number	:	763-744-8252
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SAMIRA ABDI
Credential	:
Telephone Number	:	763-744-8252

Provider Enumeration Date	:	12/26/2024
Last Update Date	:	12/26/2024

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