Provider Demographics
NPI:1891152872
Name:GOODRICH, AUSTIN GLENN (ATC)
Entity Type:Individual
Prefix:MR
First Name:AUSTIN
Middle Name:GLENN
Last Name:GOODRICH
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3046 E LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-2420
Mailing Address - Country:US
Mailing Address - Phone:209-480-1516
Mailing Address - Fax:
Practice Address - Street 1:3046 E LAUREL ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-2420
Practice Address - Country:US
Practice Address - Phone:209-480-1516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-21
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer