Provider Demographics
NPI:1821790437
Name:GOFORTH, MIRANDA
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:GOFORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6325 US ROUTE 35 E
Mailing Address - Street 2:
Mailing Address - City:WEST ALEXANDRIA
Mailing Address - State:OH
Mailing Address - Zip Code:45381-9501
Mailing Address - Country:US
Mailing Address - Phone:937-716-4571
Mailing Address - Fax:
Practice Address - Street 1:6325 US ROUTE 35 E
Practice Address - Street 2:
Practice Address - City:WEST ALEXANDRIA
Practice Address - State:OH
Practice Address - Zip Code:45381-9501
Practice Address - Country:US
Practice Address - Phone:937-716-4571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-20
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care