MEDICARE: MR. BRANDON GOODSELL

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	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1346616216
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRANDON GOODSELL

Provider Business Mailing Address
First Line	:	2487 S. 700 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106
Country	:	US
Telephone Number	:	385-261-2070
Fax Number	:	385-229-4233

Provider Business Practice Location Address
First Line	:	2487 S. 700 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106
Country	:	US
Telephone Number	:	385-261-2070
Fax Number	:	385-229-4233

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

Provider Enumeration Date	:	08/14/2015
Last Update Date	:	10/22/2021

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