Healthcare Provider Details

I. General information

NPI: 1881872950
Provider Name (Legal Business Name): KATHLEEN SUZANNE GOODRICH LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2008
Last Update Date: 01/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9990 COUNTY FARM RD STE 6
RIVERSIDE CA
92503-3542
US

IV. Provider business mailing address

13621 BLUE SPRUCE CT
MORENO VALLEY CA
92553-4377
US

V. Phone/Fax

Practice location:
  • Phone: 951-358-7380
  • Fax:
Mailing address:
  • Phone: 951-247-6246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN220746
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: