MEDICARE: MRS. LISA DIANE GOODE

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	:	1548042245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA DIANE GOODE

Provider Business Mailing Address
First Line	:	502 CHESTNUT ST
Second Line	:
City	:	GREENFIELD
State	:	IL
Zip	:	62044-1305
Country	:	US
Telephone Number	:	217-368-2667
Fax Number	:	217-368-3140

Provider Business Practice Location Address
First Line	:	502 CHESTNUT ST
Second Line	:
City	:	GREENFIELD
State	:	IL
Zip	:	62044-1305
Country	:	US
Telephone Number	:	217-368-2667
Fax Number	:	217-368-3140

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

Provider Enumeration Date	:	10/17/2023
Last Update Date	:	10/17/2023

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