Provider Demographics
NPI:1053689257
Name:FRESHPATH HEALTHCARE SERVICES
Entity Type:Organization
Organization Name:FRESHPATH HEALTHCARE SERVICES
Other - Org Name:FRESHPATH HEALTHCARE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DETRO
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-485-9182
Mailing Address - Street 1:231 SIERRA DR SE SUITE 4
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108
Mailing Address - Country:US
Mailing Address - Phone:505-508-4605
Mailing Address - Fax:505-508-4605
Practice Address - Street 1:11311 MORRISON ST APT 207
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91601-5366
Practice Address - Country:US
Practice Address - Phone:818-485-9182
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRESHPATH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-02
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM221-29774Medicaid