Provider Demographics
NPI:1124865563
Name:GOODENBERGER, TRACIE
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:GOODENBERGER
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 1:1946 S 80TH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-6508
Mailing Address - Country:US
Mailing Address - Phone:785-819-1770
Mailing Address - Fax:
Practice Address - Street 1:3543 S 85TH ST STE 200
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68520-1501
Practice Address - Country:US
Practice Address - Phone:402-986-7856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-12
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1648152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist