Provider Demographics
NPI:1003483447
Name:ETERNAL PATHWAY LLC
Entity Type:Organization
Organization Name:ETERNAL PATHWAY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-731-6917
Mailing Address - Street 1:11225 N 28TH DR STE D104
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-5609
Mailing Address - Country:US
Mailing Address - Phone:602-607-5422
Mailing Address - Fax:
Practice Address - Street 1:11225 N 28TH DR STE D104
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-5609
Practice Address - Country:US
Practice Address - Phone:602-607-5422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-04
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities