Healthcare Provider Details

I. General information

NPI: 1629197298
Provider Name (Legal Business Name): JOHN PAUL GOODMAN LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4350 WAKING SKY
SANTA FE NM
87507-2573
US

IV. Provider business mailing address

4350 WAKING SKY
SANTA FE NM
87507-2573
US

V. Phone/Fax

Practice location:
  • Phone: 505-988-4439
  • Fax:
Mailing address:
  • Phone: 505-988-4439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2961
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: