Healthcare Provider Details

I. General information

NPI: 1073910170
Provider Name (Legal Business Name): JAIMI GOODMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2014
Last Update Date: 12/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3523 CLEMSON BLVD
ANDERSON SC
29621-1312
US

IV. Provider business mailing address

3523 CLEMSON BLVD
ANDERSON SC
29621-1312
US

V. Phone/Fax

Practice location:
  • Phone: 864-332-1290
  • Fax:
Mailing address:
  • Phone: 864-332-1290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174M00000X
TaxonomyVeterinarian
License Number3401
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: