MEDICARE: DR. KENNETH MICHAEL GOODMAN D.C.

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	111N00000X	Chiropractor	349688-1202	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	71957	OTHER	UT	PEHP

General Provider Information

NPI Number	:	1700971587
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH MICHAEL GOODMAN D.C.

Provider Business Mailing Address
First Line	:	85 E STATE ROAD 73
Second Line	:
City	:	SARATOGA SPRINGS
State	:	UT
Zip	:	84043-4823
Country	:	US
Telephone Number	:	801-766-0507
Fax Number	:	801-766-0838

Provider Business Practice Location Address
First Line	:	85 E STATE ROAD 73
Second Line	:
City	:	SARATOGA SPRINGS
State	:	UT
Zip	:	84043-4823
Country	:	US
Telephone Number	:	801-766-0507
Fax Number	:	801-766-0838

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

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	07/08/2007

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