Provider Demographics
NPI:1538456348
Name:GOODWILLHOMESCOMMUNITYSERVICES, INC.
Entity Type:Organization
Organization Name:GOODWILLHOMESCOMMUNITYSERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVEOFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-785-6790
Mailing Address - Street 1:PO BOX 161282
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38186-1282
Mailing Address - Country:US
Mailing Address - Phone:901-785-6790
Mailing Address - Fax:901-789-8351
Practice Address - Street 1:4590 GOODWILL RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38109-5714
Practice Address - Country:US
Practice Address - Phone:901-785-6790
Practice Address - Fax:901-789-8351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-30
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNSO/10802A253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1450144Medicaid