=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770961567
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIFFANY GOODWIN LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2015
-----------------------------------------------------
Last Update Date | 11/13/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1043 MAKAWAO AVE STE 205C
-----------------------------------------------------
City | MAKAWAO
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96768-9465
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-646-0930
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 35 W 8TH AVE
-----------------------------------------------------
City | EUGENE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97401-2901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-686-4461
-----------------------------------------------------
Fax | 541-686-4465
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 18665
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------