Provider Demographics
NPI:1184247975
Name:GOODCLOVER, LLC
Entity type:Organization
Organization Name:GOODCLOVER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:LANDPHERE
Authorized Official - Suffix:
Authorized Official - Credentials:LCAC
Authorized Official - Phone:707-248-0818
Mailing Address - Street 1:405 MAIN AVE W UNIT 4J
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-1665
Mailing Address - Country:US
Mailing Address - Phone:701-248-0818
Mailing Address - Fax:
Practice Address - Street 1:405 MAIN AVE W UNIT 4J
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-1665
Practice Address - Country:US
Practice Address - Phone:701-248-0818
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-27
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children