Provider Demographics
NPI:1255628939
Name:GOOCHLAND FREE CLINIC AND FAMILY SERVICES, INC.
Entity type:Organization
Organization Name:GOOCHLAND FREE CLINIC AND FAMILY SERVICES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:K
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:RN-C, ANP
Authorized Official - Phone:804-556-5840
Mailing Address - Street 1:1800 SANDY HOOK RD
Mailing Address - Street 2:PO BOX 116
Mailing Address - City:GOOCHLAND
Mailing Address - State:VA
Mailing Address - Zip Code:23063-3105
Mailing Address - Country:US
Mailing Address - Phone:804-556-6260
Mailing Address - Fax:804-556-6208
Practice Address - Street 1:1800 SANDY HOOK RD
Practice Address - Street 2:
Practice Address - City:GOOCHLAND
Practice Address - State:VA
Practice Address - Zip Code:23063-3105
Practice Address - Country:US
Practice Address - Phone:804-556-6260
Practice Address - Fax:804-556-6208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-01
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001053028261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care