Provider Demographics
NPI:1235910175
Name:GOSHEN DEVELOPMENTAL DISABILITY CENTER
Entity Type:Organization
Organization Name:GOSHEN DEVELOPMENTAL DISABILITY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARCEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KALONGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-361-9868
Mailing Address - Street 1:3306 N 190TH PLZ
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-3554
Mailing Address - Country:US
Mailing Address - Phone:402-252-4497
Mailing Address - Fax:
Practice Address - Street 1:617 MORNINGSIDE RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28214-9105
Practice Address - Country:US
Practice Address - Phone:704-361-9868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-06
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child