Provider Demographics
NPI:1427027341
Name:GOODWILL INDUSTRIES OF THE VALLEYS - ROANOKE
Entity Type:Organization
Organization Name:GOODWILL INDUSTRIES OF THE VALLEYS - ROANOKE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:PHIPPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-581-0620
Mailing Address - Street 1:2502 MELROSE AVENUE NW
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24017
Mailing Address - Country:US
Mailing Address - Phone:540-581-0620
Mailing Address - Fax:540-581-0628
Practice Address - Street 1:2502 MELROSE AVENUE NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24017
Practice Address - Country:US
Practice Address - Phone:540-581-0620
Practice Address - Fax:540-581-0628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA24002006251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004946928Medicaid
VA004947444Medicaid