Provider Demographics
NPI:1366110314
Name:NORTHERN PATHWAYS
Entity type:Organization
Organization Name:NORTHERN PATHWAYS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSE DESIGNER
Authorized Official - Prefix:
Authorized Official - First Name:FRANCES
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-712-6002
Mailing Address - Street 1:12700 LINCOLN LAKE AVE.
Mailing Address - Street 2:
Mailing Address - City:GOWEN
Mailing Address - State:MI
Mailing Address - Zip Code:49326
Mailing Address - Country:US
Mailing Address - Phone:616-712-6002
Mailing Address - Fax:616-712-6002
Practice Address - Street 1:12700 LINCOLN LAKE AVE.
Practice Address - Street 2:
Practice Address - City:GOWEN
Practice Address - State:MI
Practice Address - Zip Code:49326
Practice Address - Country:US
Practice Address - Phone:616-712-6022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-03
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home