=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497098008
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOODWIN HOUSE INCORPORATED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2013
-----------------------------------------------------
Last Update Date | 01/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3440 S JEFFERSON ST
-----------------------------------------------------
City | FALLS CHURCH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22041-3145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-578-7260
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3440 S JEFFERSON ST
-----------------------------------------------------
City | FALLS CHURCH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22041-3145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF BUSINESS DEVELOPMENT OFFICER
-----------------------------------------------------
Name | ANDREW M SIEGEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 703-578-7554
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | ALF 447573-L155
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 313M00000X
-----------------------------------------------------
Taxonomy Name | Nursing Facility/Intermediate Care Facility
-----------------------------------------------------
License Number | NH2559
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------