Provider Demographics
NPI:1710014394
Name:GOODRIDGE, GEORGE WILLIAM (ATC, EMC)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:WILLIAM
Last Name:GOODRIDGE
Suffix:
Gender:M
Credentials:ATC, EMC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:792 E BRIDGEWATER CT
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-6424
Mailing Address - Country:US
Mailing Address - Phone:208-433-0024
Mailing Address - Fax:
Practice Address - Street 1:792 E BRIDGEWATER CT
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-6424
Practice Address - Country:US
Practice Address - Phone:208-433-0024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT-2482255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer