Healthcare Provider Details

I. General information

NPI: 1750439501
Provider Name (Legal Business Name): GOODWILL OF THE GREAT PLAINS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 W 4TH ST
SIOUX CITY IA
51103-3202
US

IV. Provider business mailing address

3100 W 4TH ST
SIOUX CITY IA
51103-3202
US

V. Phone/Fax

Practice location:
  • Phone: 712-258-4511
  • Fax: 712-258-7832
Mailing address:
  • Phone: 712-258-4511
  • Fax: 712-258-7832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License NumberADS005
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHAWN C FICK
Title or Position: VICE PRESIDENT MISSION ADVANCEMENT
Credential:
Phone: 712-258-4511