Provider Demographics
NPI:1477836880
Name:GOODWILL OF NORTHERN ARIZONA
Entity type:Organization
Organization Name:GOODWILL OF NORTHERN ARIZONA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP MISSION SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:LIZ
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGINLAY
Authorized Official - Suffix:
Authorized Official - Credentials:BS ED GCDF
Authorized Official - Phone:928-526-9188
Mailing Address - Street 1:4308 E RTE 66
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004
Mailing Address - Country:US
Mailing Address - Phone:928-526-9188
Mailing Address - Fax:928-526-9240
Practice Address - Street 1:2369 AIRWAY AVENUE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401
Practice Address - Country:US
Practice Address - Phone:928-526-9188
Practice Address - Fax:928-526-9240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-21
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
302F00000X
AZ251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
No302F00000XManaged Care OrganizationsExclusive Provider Organization