Provider Demographics
NPI:1093572836
Name:FATHERLY INSTRUCTION FOR REBUILDING MEN LLC
Entity Type:Organization
Organization Name:FATHERLY INSTRUCTION FOR REBUILDING MEN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARLON
Authorized Official - Middle Name:
Authorized Official - Last Name:GOOLSBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-963-2073
Mailing Address - Street 1:785 BRENTNELL AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43219-2571
Mailing Address - Country:US
Mailing Address - Phone:740-963-2073
Mailing Address - Fax:
Practice Address - Street 1:785 BRENTNELL AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219-2571
Practice Address - Country:US
Practice Address - Phone:740-963-2073
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child