Provider Demographics
NPI:1568818425
Name:GOODLIFE PHYSICAL MEDICINE CORP
Entity Type:Organization
Organization Name:GOODLIFE PHYSICAL MEDICINE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:310-543-7779
Mailing Address - Street 1:2218 E MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-6507
Mailing Address - Country:US
Mailing Address - Phone:310-648-7290
Mailing Address - Fax:
Practice Address - Street 1:2218 E MAPLE AVE
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-6507
Practice Address - Country:US
Practice Address - Phone:310-648-7290
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-10
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB255330Medicare PIN