Healthcare Provider Details

I. General information

NPI: 1679800981
Provider Name (Legal Business Name): MS. CARRIE GOODEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2009
Last Update Date: 11/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 N. 200 EAST
CEDAR CITY UT
84720
US

IV. Provider business mailing address

54 N. 200 EAST
CEDAR CITY UT
84720
US

V. Phone/Fax

Practice location:
  • Phone: 435-865-6481
  • Fax:
Mailing address:
  • Phone: 435-865-6481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number35038888-3503
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: