Healthcare Provider Details

I. General information

NPI: 1710794169
Provider Name (Legal Business Name): G.O.A.L.S. SUCCESS PAD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2024
Last Update Date: 12/23/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E LAKE CT
ANTIOCH CA
94509-2040
US

IV. Provider business mailing address

1881 HIDDEN GATE
COLUMBUS OH
43228-6531
US

V. Phone/Fax

Practice location:
  • Phone: 925-384-8723
  • Fax:
Mailing address:
  • Phone: 925-384-8723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. SARAH PACK
Title or Position: CEO/PRESIDENT
Credential:
Phone: 925-384-8723