Healthcare Provider Details

I. General information

NPI: 1669836946
Provider Name (Legal Business Name): GOODWILL MEDICAL CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2016
Last Update Date: 05/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2011 BEVERLY BLVD
LOS ANGELES CA
90057-2403
US

IV. Provider business mailing address

2011 BEVERLY BLVD
LOS ANGELES CA
90057-2403
US

V. Phone/Fax

Practice location:
  • Phone: 213-412-4777
  • Fax: 213-416-4478
Mailing address:
  • Phone: 213-412-4777
  • Fax: 213-416-4478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA50311
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberA50311
License Number StateCA

VIII. Authorized Official

Name: DR. HEIDI ANN WINKLER
Title or Position: PRESIDENT/MEDICAL DIRECTOR
Credential: M.D,
Phone: 213-413-4777