Healthcare Provider Details

I. General information

NPI: 1710531942
Provider Name (Legal Business Name): GEORGE EMIL GODDRIDGE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2019
Last Update Date: 07/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7777 GRANDE ST
SUNRISE FL
33351-6313
US

IV. Provider business mailing address

7777 GRANDE ST
SUNRISE FL
33351-6313
US

V. Phone/Fax

Practice location:
  • Phone: 954-547-2675
  • Fax:
Mailing address:
  • Phone: 954-547-2675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberJF130454
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: