Healthcare Provider Details

I. General information

NPI: 1033398847
Provider Name (Legal Business Name): CALLIE C GOOCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2007
Last Update Date: 10/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4110 US HIGHWAY 31 S
DECATUR AL
35603-1644
US

IV. Provider business mailing address

1316 SOMERVILLE RD SE SUITE 1
DECATUR AL
35601-4305
US

V. Phone/Fax

Practice location:
  • Phone: 256-355-6105
  • Fax:
Mailing address:
  • Phone: 256-355-6105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCASE MANAGER
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: