1548711583 NPI number — LAURA YASUKO GOODWELL-VELEZ ATC

Table of content: LAURA YASUKO GOODWELL-VELEZ ATC (NPI 1548711583)

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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