Provider Demographics
NPI:1861248163
Name:GOODLIFF, KEAGEN
Entity type:Individual
Prefix:
First Name:KEAGEN
Middle Name:
Last Name:GOODLIFF
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 1:1472 OLEAN PORTVILLE RD
Mailing Address - Street 2:
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760-9405
Mailing Address - Country:US
Mailing Address - Phone:716-790-8084
Mailing Address - Fax:
Practice Address - Street 1:1472 OLEAN PORTVILLE RD
Practice Address - Street 2:
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760-9405
Practice Address - Country:US
Practice Address - Phone:716-790-8084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-26
Last Update Date:2024-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY863497107332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies