Healthcare Provider Details

I. General information

NPI: 1558706945
Provider Name (Legal Business Name): EASTERSEALS-GOODWILL NORTHERN ROCKY MOUNTAIN, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2013
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 S 9TH AVE STE 103
CALDWELL ID
83605-5072
US

IV. Provider business mailing address

425 1ST AVE N
GREAT FALLS MT
59401-2507
US

V. Phone/Fax

Practice location:
  • Phone: 208-454-8555
  • Fax: 208-454-8828
Mailing address:
  • Phone: 406-771-3754
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MARK SHERMAN
Title or Position: CFO
Credential:
Phone: 406-771-3762