Healthcare Provider Details

I. General information

NPI: 1225479215
Provider Name (Legal Business Name): LAUREN GOEBBEL LAUREN GOEBBEL AT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LAUREN BLOOM LAUREN BLOOM

II. Dates (important events)

Enumeration Date: 07/08/2013
Last Update Date: 07/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3584 HOME RD
POWELL OH
43065
US

IV. Provider business mailing address

3584 HOME RD
POWELL OH
43065
US

V. Phone/Fax

Practice location:
  • Phone: 740-657-4263
  • Fax: 740-657-4297
Mailing address:
  • Phone: 740-657-4263
  • Fax: 740-657-4297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT002490
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: