1639191562 NPI number — COUNTY OF GOSHEN

Table of content: (NPI 1639191562)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639191562 NPI number — COUNTY OF GOSHEN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTY OF GOSHEN
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639191562
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/01/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2025 CAMPBELL DR
Provider Second Line Business Mailing Address:
#1
Provider Business Mailing Address City Name:
TORRINGTON
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82240-1548
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-532-4069
Provider Business Mailing Address Fax Number:
307-532-4060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2025 CAMPBELL DR
Provider Second Line Business Practice Location Address:
#1
Provider Business Practice Location Address City Name:
TORRINGTON
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82240-1548
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-532-4069
Provider Business Practice Location Address Fax Number:
307-532-4060
Provider Enumeration Date:
07/23/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GRACE
Authorized Official First Name:
CATHY
Authorized Official Middle Name:
G
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
307-532-4069

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  07-162 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251K00000X , with the licence number: 07-162 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 109199900 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 107249800 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 107249803 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".