Provider Demographics
NPI:1730670225
Name:GODDARD, DANIEL LEE
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:LEE
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 1:436 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7018
Mailing Address - Country:US
Mailing Address - Phone:907-376-8020
Mailing Address - Fax:907-376-8017
Practice Address - Street 1:436 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7018
Practice Address - Country:US
Practice Address - Phone:907-376-8020
Practice Address - Fax:907-376-8017
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist