1144653866 NPI number — MARTHA RIEDEL-BROMFIELD GOODWIN DPT

Table of content: MARTHA RIEDEL-BROMFIELD GOODWIN DPT (NPI 1144653866)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144653866 NPI number — MARTHA RIEDEL-BROMFIELD GOODWIN DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOODWIN
Provider First Name:
MARTHA
Provider Middle Name:
RIEDEL-BROMFIELD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144653866
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1850 N EDGEMONT ST
Provider Second Line Business Mailing Address:
APT 2
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90027-4104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-624-8198
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
321 N LARCHMONT BLVD STE 825
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90004-6400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-464-4458
Provider Business Practice Location Address Fax Number:
323-464-5329
Provider Enumeration Date:
08/16/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT40393 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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