1104067008 NPI number — GOODWILL OF NORTHERN ARIZONA

Table of content: (NPI 1104067008)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104067008 NPI number — GOODWILL OF NORTHERN ARIZONA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOODWILL OF NORTHERN ARIZONA
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:
1104067008
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1060
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLAGSTAFF
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86002-1060
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-526-9188
Provider Business Mailing Address Fax Number:
928-526-9240

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2225 N STEVES BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLAGSTAFF
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86004-6115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-526-9188
Provider Business Practice Location Address Fax Number:
928-526-9240
Provider Enumeration Date:
03/23/2009

Additional Information

Authorized Official

Authorized Official Last Name:
HIRSCH
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
928-526-9188

Provider Taxonomy Codes

  • Taxonomy code: 251V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 019522 . This is a "AHCCCS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com