Healthcare Provider Details

I. General information

NPI: 1477836880
Provider Name (Legal Business Name): GOODWILL OF NORTHERN ARIZONA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2011
Last Update Date: 11/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2369 AIRWAY AVENUE
KINGMAN AZ
86401
US

IV. Provider business mailing address

4308 E RTE 66
FLAGSTAFF AZ
86004
US

V. Phone/Fax

Practice location:
  • Phone: 928-526-9188
  • Fax: 928-526-9240
Mailing address:
  • Phone: 928-526-9188
  • Fax: 928-526-9240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: LIZ MCGINLAY
Title or Position: VP MISSION SERVICES
Credential: BS ED GCDF
Phone: 928-526-9188