Provider Demographics
NPI:1356469712
Name:PATHWAY TO SUCCESS
Entity Type:Organization
Organization Name:PATHWAY TO SUCCESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:STELLA
Authorized Official - Middle Name:K
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-229-2008
Mailing Address - Street 1:2445 HILLFORD DR
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27217-3173
Mailing Address - Country:US
Mailing Address - Phone:336-229-5580
Mailing Address - Fax:336-229-2008
Practice Address - Street 1:112 STAGG ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27217-2654
Practice Address - Country:US
Practice Address - Phone:336-229-2008
Practice Address - Fax:336-229-2008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-001-028311Z00000X
320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805484Medicaid