=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063245934
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOALS SUPPORTIVE SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2024
-----------------------------------------------------
Last Update Date | 08/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4139 DUFFY CT
-----------------------------------------------------
City | FAIRFIELD TOWNSHIP
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45011-9389
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-212-5655
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4139 DUFFY CT
-----------------------------------------------------
City | FAIRFIELD TOWNSHIP
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45011-9389
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-212-5655
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | SILVA RICHARDSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 513-212-5655
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 347C00000X
-----------------------------------------------------
Taxonomy Name | Private Vehicle
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------