MEDICARE: GOODLIFE PHYSICAL MEDICINE CORP

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	208100000X	Physical Medicine & Rehabilitation Physician
2	332B00000X	Durable Medical Equipment & Medical Supplies
3	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1568818425
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOODLIFE PHYSICAL MEDICINE CORP

Provider Business Mailing Address
First Line	:	2218 E MAPLE AVE
Second Line	:
City	:	EL SEGUNDO
State	:	CA
Zip	:	90245-6507
Country	:	US
Telephone Number	:	310-648-7290
Fax Number	:

Provider Business Practice Location Address
First Line	:	2218 E MAPLE AVE
Second Line	:
City	:	EL SEGUNDO
State	:	CA
Zip	:	90245-6507
Country	:	US
Telephone Number	:	310-648-7290
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. DAVE CARRY
Credential	:	DC
Telephone Number	:	310-543-7779

Provider Enumeration Date	:	05/10/2016
Last Update Date	:	06/09/2017

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Directions to “GOODLIFE PHYSICAL MEDICINE CORP ” Practice Location

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