Healthcare Provider Details

I. General information

NPI: 1205802899
Provider Name (Legal Business Name): GOODWIN STREET MEDICAL SUPPLY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 05/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 W GOODWIN ST STE 1
PRESCOTT AZ
86303-3737
US

IV. Provider business mailing address

406 W GOODWIN ST STE 1
PRESCOTT AZ
86303-3737
US

V. Phone/Fax

Practice location:
  • Phone: 928-541-1825
  • Fax: 928-541-1823
Mailing address:
  • Phone: 928-541-1825
  • Fax: 928-541-1823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number20002621
License Number StateAZ

VIII. Authorized Official

Name: MICHELLE IRENE HEROD
Title or Position: OWNER
Credential:
Phone: 928-541-1825