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General NPI Number Information
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NPI Number | 1043933658
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Entity Type | Individual
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Provider Name | ALEXANDER D GOODRIDGE PTA
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Gender | Male
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Dates
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Enumeration Date | 09/20/2022
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Last Update Date | 09/20/2022
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Provider Practice Location Address
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Address Line | 555 BIESTERFIELD RD
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City | ELK GROVE VILLAGE
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State | IL
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Zip | 60007-3306
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Country | US
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Telephone | 847-690-9360
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Fax |
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Provider Business Mailing Address
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Address Line | 2122 YORK RD STE 300
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City | OAK BROOK
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State | IL
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Zip | 60523-1925
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Country | US
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Telephone | 630-575-1980
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Fax | 630-928-5080
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 160009566
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License Number State | IL
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