MEDICARE: CARLOS GODOY

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	171W00000X	Contractor	6954828	AZ

General Provider Information

NPI Number	:	1215316120
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLOS GODOY

Provider Business Mailing Address
First Line	:	INTERMOUNTAIN CENTERS FOR HUMAN DEVELOPMENT INC
Second Line	:	994 S HARRISON RD
City	:	TUCSON
State	:	AZ
Zip	:	85748
Country	:	US
Telephone Number	:	520-721-1887
Fax Number	:

Provider Business Practice Location Address
First Line	:	6108 E BRAMBLE ST
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85756
Country	:	US
Telephone Number	:	520-437-2437
Fax Number	:

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

Provider Enumeration Date	:	05/26/2015
Last Update Date	:	11/12/2019

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Directions to “ CARLOS GODOY ” Practice Location

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