MEDICARE: ANDREW GOFORTH LMT.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172M00000X	Mechanotherapist	7501007374	MI

General Provider Information

NPI Number	:	1124562954
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREW GOFORTH LMT.

Provider Business Mailing Address
First Line	:	3308 ARBOR DR.
Second Line	:
City	:	FENTON
State	:	MI
Zip	:	48430-3127
Country	:	US
Telephone Number	:	810-333-7990
Fax Number	:	810-215-1086

Provider Business Practice Location Address
First Line	:	3308 ARBOR DR
Second Line	:
City	:	FENTON
State	:	MI
Zip	:	48430-3127
Country	:	US
Telephone Number	:	810-333-7990
Fax Number	:	810-215-1086

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/13/2016
Last Update Date	:	12/13/2016

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