1295839413 NPI number — GOODE 2 FEET

Table of content: (NPI 1295839413)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295839413 NPI number — GOODE 2 FEET

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOODE 2 FEET
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1295839413
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6109 HOLYOAKE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23224-5717
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
434-348-3130
Provider Business Mailing Address Fax Number:
804-745-3468

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
425 S MAIN ST STE F
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EMPORIA
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23847-2300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-348-3130
Provider Business Practice Location Address Fax Number:
804-745-3468
Provider Enumeration Date:
09/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EDWARDS
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
GOODE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
434-348-3130

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1847344 . This is a "CIGNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 278060 . This is a "MAMSI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 278060 . This is a "ALLIANCE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 6298858 . This is a "GHI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 7956331 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 210584 . This is a "SOUTHERN HEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 454380 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 9303502 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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