Provider Demographics
NPI:1073270427
Name:GOSHEN HEALTH SERVICES LLC
Entity Type:Organization
Organization Name:GOSHEN HEALTH SERVICES LLC
Other - Org Name:DOMINION HEALTHCARE SERVICES L
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:YARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BANGURA
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:612-258-8794
Mailing Address - Street 1:5421 PENN AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55430-2943
Mailing Address - Country:US
Mailing Address - Phone:612-258-8794
Mailing Address - Fax:
Practice Address - Street 1:5421 PENN AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-2943
Practice Address - Country:US
Practice Address - Phone:612-258-8794
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-19
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)