=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568056406
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TUNESE GOODWIN PROTHETIC SPECIALIST
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2021
-----------------------------------------------------
Last Update Date | 02/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 798 FORT CROOK RD S
-----------------------------------------------------
City | BELLEVUE
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68005-2964
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-598-4443
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6024 N 107TH ST
-----------------------------------------------------
City | OMAHA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68134-1044
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-598-4443
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1744P3200X
-----------------------------------------------------
Taxonomy Name | Prosthetics Case Management
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------