1902234685 NPI number — MY GOAL OUR MISSION SERVICES, LLC

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 1902234685 NPI number — MY GOAL OUR MISSION SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MY GOAL OUR MISSION SERVICES, LLC
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:
1902234685
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/24/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
208 FOREST HILLS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARNER
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27529-3624
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-800-0016
Provider Business Mailing Address Fax Number:
866-812-0587

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
235 WEST LAKE DR
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-800-0016
Provider Business Practice Location Address Fax Number:
866-812-0587
Provider Enumeration Date:
10/16/2013

Additional Information

Authorized Official

Authorized Official Last Name:
CHISLEY
Authorized Official First Name:
ALLISON
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
919-523-8651

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6008212 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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