Provider Demographics
NPI:1558593830
Name:EASTERSEALS-GOODWILL NORTHERN ROCKY MOUNTAIN, INC.
Entity Type:Organization
Organization Name:EASTERSEALS-GOODWILL NORTHERN ROCKY MOUNTAIN, INC.
Other - Org Name:ESGW EARLY INTERVENTION PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SHERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-771-3762
Mailing Address - Street 1:425 1ST AVE N
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59401-2507
Mailing Address - Country:US
Mailing Address - Phone:406-761-3680
Mailing Address - Fax:406-761-1390
Practice Address - Street 1:5242 SOUTH 4820 WEST
Practice Address - Street 2:ATT JANET WADE
Practice Address - City:KEARNS
Practice Address - State:UT
Practice Address - Zip Code:84118
Practice Address - Country:US
Practice Address - Phone:801-633-2091
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-20
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency