Healthcare Provider Details

I. General information

NPI: 1861248163
Provider Name (Legal Business Name): KEAGEN GOODLIFF
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2024
Last Update Date: 04/27/2024
Certification Date: 04/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1472 OLEAN PORTVILLE RD
OLEAN NY
14760-9405
US

IV. Provider business mailing address

1472 OLEAN PORTVILLE RD
OLEAN NY
14760-9405
US

V. Phone/Fax

Practice location:
  • Phone: 716-790-8084
  • Fax:
Mailing address:
  • Phone: 716-790-8084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number863497107
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: