MEDICARE: MS. LARA GOODELL P.T.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	9926A	AZ

General Provider Information

NPI Number	:	1215276217
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LARA GOODELL P.T.A.

Provider Business Mailing Address
First Line	:	297 LAKE HAVASU AVE S STE 102
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-6526
Country	:	US
Telephone Number	:	928-453-0501
Fax Number	:	928-453-0502

Provider Business Practice Location Address
First Line	:	297 LAKE HAVASU AVE S STE 102
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-6526
Country	:	US
Telephone Number	:	928-453-0501
Fax Number	:	928-453-0502

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/11/2013
Last Update Date	:	02/11/2013

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