Provider Demographics
NPI:1073639209
Name:GASTON LINCOLN CLEVELAND MHDDSA PROGRAM
Entity Type:Organization
Organization Name:GASTON LINCOLN CLEVELAND MHDDSA PROGRAM
Other - Org Name:PATHWAYS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AREA DIRECTOR/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RHETT
Authorized Official - Middle Name:
Authorized Official - Last Name:MELTON
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:704-842-6328
Mailing Address - Street 1:901 S NEW HOPE RD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-5829
Mailing Address - Country:US
Mailing Address - Phone:704-884-2501
Mailing Address - Fax:704-854-4203
Practice Address - Street 1:901 S NEW HOPE RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-5829
Practice Address - Country:US
Practice Address - Phone:704-884-2501
Practice Address - Fax:704-854-4203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301438GMedicaid
NC8301438LMedicaid
NC8301438QMedicaid
NC8301438CMedicaid
NC8301438PMedicaid
NC8301438Medicaid
NC8301438OMedicaid
NC8301438BMedicaid
NC8301438MMedicaid
NC8301438DMedicaid