Healthcare Provider Details

I. General information

NPI: 1265530331
Provider Name (Legal Business Name): LARRY KENNETH GOODWIN D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 LAKE SHORE LANE
MANSFIELD AR
72944
US

IV. Provider business mailing address

2100 LAKE SHORE LANE P.O. BOX 692
MANSFIELD AR
72944
US

V. Phone/Fax

Practice location:
  • Phone: 479-462-7891
  • Fax:
Mailing address:
  • Phone: 479-462-7891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1035
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: