Provider Demographics
NPI:1649090168
Name:5 GOODMEN COMMUNITY CARE GROUP HOME LLC
Entity type:Organization
Organization Name:5 GOODMEN COMMUNITY CARE GROUP HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:BA DEGREE
Authorized Official - Phone:414-309-2740
Mailing Address - Street 1:942 N 29TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208-3406
Mailing Address - Country:US
Mailing Address - Phone:414-988-5321
Mailing Address - Fax:
Practice Address - Street 1:942 N 29TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-3406
Practice Address - Country:US
Practice Address - Phone:414-988-5321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities