=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154841831
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES ERIC GOFORTH CRNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2017
-----------------------------------------------------
Last Update Date | 06/22/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 DOCTORS DR
-----------------------------------------------------
City | DOTHAN
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36301-2949
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-794-6611
-----------------------------------------------------
Fax | 334-794-6614
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 65 COUNTY ROAD 679
-----------------------------------------------------
City | COFFEE SPRINGS
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36318-6051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-494-8485
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 1-097156
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | 1-097156
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number | 1-097156
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------