1750439501 NPI number — GOODWILL OF THE GREAT PLAINS

Table of content: (NPI 1750439501)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750439501 NPI number — GOODWILL OF THE GREAT PLAINS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOODWILL OF THE GREAT PLAINS
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:
WALL STREET MISSION
Provider Other Organization Name Type Code:
4
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:
1750439501
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3100 W 4TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX CITY
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51103-3202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-258-4511
Provider Business Mailing Address Fax Number:
712-258-7832

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3100 W 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIOUX CITY
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51103-3202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-258-4511
Provider Business Practice Location Address Fax Number:
712-258-7832
Provider Enumeration Date:
01/08/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FICK
Authorized Official First Name:
SHAWN
Authorized Official Middle Name:
C
Authorized Official Title or Position:
VICE PRESIDENT MISSION ADVANCEMENT
Authorized Official Telephone Number:
712-258-4511

Provider Taxonomy Codes

  • Taxonomy code: 251V00000X , with the licence number:  ADS005 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QA0600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QD1600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0082081 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0236539 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".