Healthcare Provider Details

I. General information

NPI: 1679698195
Provider Name (Legal Business Name): GOODWILL INDUSTRIES NWNC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 10/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 THORNBURG DR SE
CONOVER NC
28613-8845
US

IV. Provider business mailing address

413 THORNBURG DR SE
CONOVER NC
28613-8845
US

V. Phone/Fax

Practice location:
  • Phone: 828-465-0371
  • Fax:
Mailing address:
  • Phone: 828-465-0371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License NumberMHL-018-075
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberMHL-018-075
License Number StateNC

VIII. Authorized Official

Name: MR. MALLA TONGCHY VUE
Title or Position: HICKORY DISTRICT DIRECTOR
Credential:
Phone: 828-465-0371