MEDICARE: MS. KRISTA L GOODING PT

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	225100000X	Physical Therapist	070.017546	IL

General Provider Information

NPI Number	:	1841805058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KRISTA L GOODING PT

Provider Business Mailing Address
First Line	:	PO BOX 1343
Second Line	:
City	:	GRANITE CITY
State	:	IL
Zip	:	62040-1343
Country	:	US
Telephone Number	:	618-452-1986
Fax Number	:	618-452-6814

Provider Business Practice Location Address
First Line	:	1525 JOHNSON RD
Second Line	:
City	:	GRANITE CITY
State	:	IL
Zip	:	62040-3831
Country	:	US
Telephone Number	:	618-452-1986
Fax Number	:	618-452-6814

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

Provider Enumeration Date	:	09/14/2020
Last Update Date	:	09/14/2020

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