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General NPI Number Information
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NPI Number | 1114478542
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Entity Type | Individual
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Provider Name | CARRESHA GOODLOW
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Gender | Female
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Dates
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Enumeration Date | 10/20/2016
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Last Update Date | 10/20/2016
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Provider Practice Location Address
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Address Line | W8007 SOUTH US 141/2 #334
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City | IRON
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State | MI
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Zip | 49801-9466
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Country | US
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Telephone | 731-444-2577
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 6561
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City | MILWAUKEE
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State | WI
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Zip | 53206-0561
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Country | US
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Telephone | 731-444-2577
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Fax |
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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 | 1744P3200X
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Taxonomy Name | Prosthetics Case Management
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License Number | 2701437960
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License Number State | MI
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