Provider Demographics
NPI:1306662903
Name:PATHWAY CAMP MITNICK LLC
Entity type:Organization
Organization Name:PATHWAY CAMP MITNICK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ALESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-464-3668
Mailing Address - Street 1:PO BOX 311206
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36331-1206
Mailing Address - Country:US
Mailing Address - Phone:334-464-3668
Mailing Address - Fax:
Practice Address - Street 1:4436 CALUMET LOOP
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501-7845
Practice Address - Country:US
Practice Address - Phone:334-464-3668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-27
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children