Provider Demographics
NPI:1225527989
Name:GOODE PROVIDER
Entity Type:Organization
Organization Name:GOODE PROVIDER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:346-262-2669
Mailing Address - Street 1:PO BOX 342322
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38184-2322
Mailing Address - Country:US
Mailing Address - Phone:901-230-2269
Mailing Address - Fax:
Practice Address - Street 1:2969 MOUNTAIN TERRACE ST
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38127-8335
Practice Address - Country:US
Practice Address - Phone:901-821-1123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-08
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
No253Z00000XAgenciesIn Home Supportive CareGroup - Single Specialty