Healthcare Provider Details

I. General information

NPI: 1326792003
Provider Name (Legal Business Name): DARREN ROBERT GOODWIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2022
Last Update Date: 02/10/2022
Certification Date: 02/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6330 N FIR RD
GRANGER IN
46530-4753
US

IV. Provider business mailing address

50837 SAFARI DR
GRANGER IN
46530-9021
US

V. Phone/Fax

Practice location:
  • Phone: 574-234-5557
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06002311A
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: