Healthcare Provider Details

I. General information

NPI: 1568818425
Provider Name (Legal Business Name): GOODLIFE PHYSICAL MEDICINE CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2016
Last Update Date: 06/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2218 E MAPLE AVE
EL SEGUNDO CA
90245-6507
US

IV. Provider business mailing address

2218 E MAPLE AVE
EL SEGUNDO CA
90245-6507
US

V. Phone/Fax

Practice location:
  • Phone: 310-648-7290
  • Fax:
Mailing address:
  • Phone: 310-648-7290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. DAVE CARRY
Title or Position: MANAGER
Credential: DC
Phone: 310-543-7779