Healthcare Provider Details

I. General information

NPI: 1225814395
Provider Name (Legal Business Name): PEYTON ANNE GOODRICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2023
Last Update Date: 09/05/2023
Certification Date: 09/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5122 W 95TH ST
OAK LAWN IL
60453-2458
US

IV. Provider business mailing address

5122 W 95TH ST
OAK LAWN IL
60453-2458
US

V. Phone/Fax

Practice location:
  • Phone: 708-499-3480
  • Fax:
Mailing address:
  • Phone: 708-499-3480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number3509
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: