Provider Demographics
NPI:1154790368
Name:GOODSPEED
Entity type:Organization
Organization Name:GOODSPEED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-223-6180
Mailing Address - Street 1:79 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-2152
Mailing Address - Country:US
Mailing Address - Phone:585-223-6180
Mailing Address - Fax:585-223-6529
Practice Address - Street 1:79 WEST AVE
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-2152
Practice Address - Country:US
Practice Address - Phone:585-223-6180
Practice Address - Fax:585-223-6529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-17
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02617045Medicaid