1124679436 NPI number — DOCTORS GOODWILL FOUNDATION, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124679436 NPI number — DOCTORS GOODWILL FOUNDATION, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOCTORS GOODWILL FOUNDATION, INC
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:
1124679436
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 INDIAN RIVER AVE APT 1001
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TITUSVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32796-5821
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-298-5531
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
123 S PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TITUSVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32796-3377
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-567-4869
Provider Business Practice Location Address Fax Number:
321-567-4874
Provider Enumeration Date:
09/27/2019

Additional Information

Authorized Official

Authorized Official Last Name:
BHALANI
Authorized Official First Name:
KANTILAL
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
321-298-5531

Provider Taxonomy Codes

  • Taxonomy code: 261QC1500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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