Provider Demographics
NPI:1447004262
Name:GOFORTH RESIDENTIAL SERVICES LLC
Entity type:Organization
Organization Name:GOFORTH RESIDENTIAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:SINZINKAYO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-269-8299
Mailing Address - Street 1:2413 PROPHETSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-5921
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2413 PROPHETSTOWN RD
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-5921
Practice Address - Country:US
Practice Address - Phone:518-269-8299
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-16
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities