=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518517523
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JESSICA GOIFFON PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2019
-----------------------------------------------------
Last Update Date | 09/12/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 123 MAIN ST
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 68432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-977-5300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5085 ADINA CIR
-----------------------------------------------------
City | NORTH PORT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34291-6304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JESSICA GOIFFON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 608-977-5300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------