1982491361 NPI number — GOODE PROVIDER

Table of content: (NPI 1982491361)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982491361 NPI number — GOODE PROVIDER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOODE PROVIDER
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:
1982491361
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 342322
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BARTLETT
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38184-2322
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1630 GOODMAN RD E STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHAVEN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38671-9556
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-470-7232
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/21/2025

Additional Information

Authorized Official

Authorized Official Last Name:
GOODE
Authorized Official First Name:
COURTNEY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
662-470-7232

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: Q102274 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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