MEDICARE: CHAQUIRAH GOODMAN

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	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1720606007
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHAQUIRAH GOODMAN

Provider Business Mailing Address
First Line	:	2249 VILLA VERANO WAY APT 303
Second Line	:
City	:	KISSIMMEE
State	:	FL
Zip	:	34744-5970
Country	:	US
Telephone Number	:	954-798-6651
Fax Number	:

Provider Business Practice Location Address
First Line	:	2300 S POINCIANA BLVD
Second Line	:
City	:	KISSIMMEE
State	:	FL
Zip	:	34758-2400
Country	:	US
Telephone Number	:	407-870-4860
Fax Number	:

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

Provider Enumeration Date	:	07/13/2020
Last Update Date	:	07/13/2020

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