Provider Demographics
NPI:1881946457
Name:COUNTY OF GRANT
Entity type:Organization
Organization Name:COUNTY OF GRANT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:509-765-9239
Mailing Address - Street 1:1103 LOWRY ST
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-3164
Mailing Address - Country:US
Mailing Address - Phone:509-762-1161
Mailing Address - Fax:509-762-6922
Practice Address - Street 1:1103 LOWRY ST
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-3164
Practice Address - Country:US
Practice Address - Phone:509-762-1161
Practice Address - Fax:509-762-6922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-08
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA200012501Medicaid