Provider Demographics
NPI:1871990432
Name:GOODRICH, AUTUMN (LAC, MACOM)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:GOODRICH
Suffix:
Gender:F
Credentials:LAC, MACOM
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 1512
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59771-1512
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1276 N 15TH AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-3289
Practice Address - Country:US
Practice Address - Phone:406-924-3098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-25
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT34762171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist