1548711583 NPI number — LAURA YASUKO GOODWELL-VELEZ ATC

Table of content: JEFFREY YIP JUN LEE (NPI 1245978717)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548711583 NPI number — LAURA YASUKO GOODWELL-VELEZ ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOODWELL-VELEZ
Provider First Name:
LAURA
Provider Middle Name:
YASUKO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ATC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GOODWELL
Provider Other First Name:
LAURA
Provider Other Middle Name:
YASUKO
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
ATC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1548711583
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/14/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2621 GLENROSE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALTADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91001-5031
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5719 WIDEWATERS PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SYRACUSE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13214-1985
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-883-5886
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/14/2016

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: 2255A2300X , with the licence number:  003202-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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