Healthcare Provider Details

I. General information

NPI: 1528317278
Provider Name (Legal Business Name): CHRISTOPHER MICHAEL GOODRICH CISSP-ISSEP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2012
Last Update Date: 09/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 PEQUIN TRL SE
ALBUQUERQUE NM
87123-2174
US

IV. Provider business mailing address

308 PEQUIN TRL SE
ALBUQUERQUE NM
87123-2174
US

V. Phone/Fax

Practice location:
  • Phone: 505-227-6130
  • Fax:
Mailing address:
  • Phone: 505-227-6130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1T3412
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number1T3412
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number1T3412
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number1T3412
License Number StateNM
# 5
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number1T3412
License Number StateNM
# 6
Primary TaxonomyN
Taxonomy Code372500000X
TaxonomyChore Provider
License Number1T3412
License Number StateNM
# 7
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number1T3412
License Number StateNM
# 8
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number1T3412
License Number StateNM
# 9
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number1T3412
License Number StateNM
# 10
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number1T3412
License Number StateNM
# 11
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number1T3412
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: