MEDICARE: LANCE RUEBEN GOLDSON JR.

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	251S00000X	Community/Behavioral Health Agency		OH

General Provider Information

NPI Number	:	1679258925
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LANCE RUEBEN GOLDSON JR.

Provider Business Mailing Address
First Line	:	2211 LAKE CLUB DR
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43232-3204
Country	:	US
Telephone Number	:	614-704-5224
Fax Number	:	614-515-2693

Provider Business Practice Location Address
First Line	:	2211 LAKE CLUB DR
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43232-3204
Country	:	US
Telephone Number	:	614-704-5224
Fax Number	:	614-515-2693

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

Provider Enumeration Date	:	06/15/2023
Last Update Date	:	06/15/2023

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