Provider Demographics
NPI:1831881481
Name:GOODWIN HOUSE HOME AND COMMUNITY BASED SERVICES
Entity type:Organization
Organization Name:GOODWIN HOUSE HOME AND COMMUNITY BASED SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP PERFORMANCE AND OPERATIONS, HCBS
Authorized Official - Prefix:
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:T
Authorized Official - Last Name:GREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-578-7195
Mailing Address - Street 1:4800 FILLMORE AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22311-5070
Mailing Address - Country:US
Mailing Address - Phone:703-578-7195
Mailing Address - Fax:
Practice Address - Street 1:5000 FAIRBANKS AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22311-1246
Practice Address - Country:US
Practice Address - Phone:703-797-3869
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GOODWIN HOUSE INCORPORATED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty