Healthcare Provider Details

I. General information

NPI: 1508218991
Provider Name (Legal Business Name): WILL GOODWIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2016
Last Update Date: 07/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 S MAUVILLA DR
CHICKASAW AL
36611-1244
US

IV. Provider business mailing address

157 S MAUVILLA DR
CHICKASAW AL
36611-1244
US

V. Phone/Fax

Practice location:
  • Phone: 251-610-5557
  • Fax:
Mailing address:
  • Phone: 251-610-5557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number165554
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: