Provider Demographics
NPI:1548559438
Name:GODFREY, JOHN DAHL (ATC/PTA)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:DAHL
Last Name:GODFREY
Suffix:
Gender:M
Credentials:ATC/PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6049 N 1ST ST STE 101
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-5449
Mailing Address - Country:US
Mailing Address - Phone:559-432-0524
Mailing Address - Fax:559-449-8646
Practice Address - Street 1:6049 N 1ST ST STE 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-5449
Practice Address - Country:US
Practice Address - Phone:559-432-0524
Practice Address - Fax:559-449-8646
Is Sole Proprietor?:No
Enumeration Date:2011-03-31
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT1938225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant