Provider Demographics
NPI:1346058328
Name:GOFAN HEALTHCARE SERVICE LLC
Entity type:Organization
Organization Name:GOFAN HEALTHCARE SERVICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACINTA
Authorized Official - Middle Name:
Authorized Official - Last Name:MADU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-469-0044
Mailing Address - Street 1:2072 ROYAL ACRES TRL
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75036-8772
Mailing Address - Country:US
Mailing Address - Phone:469-296-8177
Mailing Address - Fax:972-435-4426
Practice Address - Street 1:6200 BALTIMORE AVE STE 300
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:MD
Practice Address - Zip Code:20737-1054
Practice Address - Country:US
Practice Address - Phone:469-296-8177
Practice Address - Fax:469-722-5748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-23
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty