MEDICARE: MR. KEVIN L GOODWIN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	343900000X	Non-emergency Medical Transport (VAN)

General Provider Information

NPI Number	:	1629728662
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEVIN L GOODWIN

Provider Business Mailing Address
First Line	:	PO BOX 15692
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32406-5692
Country	:	US
Telephone Number	:	850-960-1611
Fax Number	:

Provider Business Practice Location Address
First Line	:	5138 LANCE ST APT C
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32404-6973
Country	:	US
Telephone Number	:	850-960-1611
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/24/2022
Last Update Date	:	03/24/2022

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