Healthcare Provider Details

I. General information

NPI: 1811816598
Provider Name (Legal Business Name): KYLE WAYNE GOODWIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4880 MARKET ST
VENTURA CA
93003-7783
US

IV. Provider business mailing address

4880 MARKET ST
VENTURA CA
93003-7783
US

V. Phone/Fax

Practice location:
  • Phone: 661-498-9940
  • Fax:
Mailing address:
  • Phone: 661-498-9940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: