Provider Demographics
NPI:1750021150
Name:GODWIN, LAWRENCE BRUCE (MAC LAC)
Entity type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:BRUCE
Last Name:GODWIN
Suffix:
Gender:M
Credentials:MAC LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1548
Mailing Address - Street 2:
Mailing Address - City:BIGFORK
Mailing Address - State:MT
Mailing Address - Zip Code:59911-1548
Mailing Address - Country:US
Mailing Address - Phone:571-239-1727
Mailing Address - Fax:
Practice Address - Street 1:8000 HWY 35, SUITE 4
Practice Address - Street 2:
Practice Address - City:BIGFORK
Practice Address - State:MT
Practice Address - Zip Code:59911
Practice Address - Country:US
Practice Address - Phone:571-239-1728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-01
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-ACU-LIC-37875171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty