Provider Demographics
NPI:1124562954
Name:GOFORTH, ANDREW (LMT)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:GOFORTH
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3308 ARBOR DR.
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-3127
Mailing Address - Country:US
Mailing Address - Phone:810-333-7990
Mailing Address - Fax:810-215-1086
Practice Address - Street 1:3308 ARBOR DR
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-3127
Practice Address - Country:US
Practice Address - Phone:810-333-7990
Practice Address - Fax:810-215-1086
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501007374172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist