Provider Demographics
NPI:1902234685
Name:MY GOAL OUR MISSION SERVICES, LLC
Entity Type:Organization
Organization Name:MY GOAL OUR MISSION SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CHISLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-523-8651
Mailing Address - Street 1:208 FOREST HILLS DR
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-3624
Mailing Address - Country:US
Mailing Address - Phone:919-800-0016
Mailing Address - Fax:866-812-0587
Practice Address - Street 1:235 WEST LAKE DR
Practice Address - Street 2:SUITE 201
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314
Practice Address - Country:US
Practice Address - Phone:919-800-0016
Practice Address - Fax:866-812-0587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-16
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6008212Medicaid