Healthcare Provider Details

I. General information

NPI: 1972562775
Provider Name (Legal Business Name): KENNETH GOEWEY
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 GARDEN LAKES BLVD NW SUITE D
ROME GA
30165-1100
US

IV. Provider business mailing address

2400 GARDEN LAKES BLVD NW SUITE D
ROME GA
30165-1100
US

V. Phone/Fax

Practice location:
  • Phone: 706-232-6600
  • Fax: 706-232-6677
Mailing address:
  • Phone: 706-232-6600
  • Fax: 706-232-6677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number000989
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: