Provider Demographics
NPI:1407472590
Name:GODDARD, MICHAEL K
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:K
Last Name:GODDARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 11TH ST
Mailing Address - Street 2:
Mailing Address - City:RAINELLE
Mailing Address - State:WV
Mailing Address - Zip Code:25962-1255
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:348 NORTHRIDGE DR APT 104
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901-9053
Practice Address - Country:US
Practice Address - Phone:304-520-4379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist