Provider Demographics
NPI:1639191562
Name:COUNTY OF GOSHEN
Entity Type:Organization
Organization Name:COUNTY OF GOSHEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:G
Authorized Official - Last Name:GRACE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:307-532-4069
Mailing Address - Street 1:2025 CAMPBELL DR
Mailing Address - Street 2:#1
Mailing Address - City:TORRINGTON
Mailing Address - State:WY
Mailing Address - Zip Code:82240-1548
Mailing Address - Country:US
Mailing Address - Phone:307-532-4069
Mailing Address - Fax:307-532-4060
Practice Address - Street 1:2025 CAMPBELL DR
Practice Address - Street 2:#1
Practice Address - City:TORRINGTON
Practice Address - State:WY
Practice Address - Zip Code:82240-1548
Practice Address - Country:US
Practice Address - Phone:307-532-4069
Practice Address - Fax:307-532-4060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY07-162251E00000X, 251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY109199900Medicaid
WY107249800Medicaid
WY107249803Medicaid
WY107249800Medicaid