Healthcare Provider Details

I. General information

NPI: 1124562954
Provider Name (Legal Business Name): ANDREW GOFORTH LMT.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2016
Last Update Date: 12/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3308 ARBOR DR
FENTON MI
48430-3127
US

IV. Provider business mailing address

3308 ARBOR DR.
FENTON MI
48430-3127
US

V. Phone/Fax

Practice location:
  • Phone: 810-333-7990
  • Fax: 810-215-1086
Mailing address:
  • Phone: 810-333-7990
  • Fax: 810-215-1086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number7501007374
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: