Provider Demographics
NPI:1730204116
Name:EASTERSEALS-GOODWILL NORTHERN ROCKY MOUNTAIN, INC.
Entity type:Organization
Organization Name:EASTERSEALS-GOODWILL NORTHERN ROCKY MOUNTAIN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SHERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-771-3762
Mailing Address - Street 1:425 1ST AVE N
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59401-2507
Mailing Address - Country:US
Mailing Address - Phone:406-761-3680
Mailing Address - Fax:406-761-1390
Practice Address - Street 1:1465 S VINNELL WAY
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1659
Practice Address - Country:US
Practice Address - Phone:208-378-9924
Practice Address - Fax:208-378-9965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID80636100Medicaid
ID806648000Medicaid
ID806361001Medicaid