MEDICARE: GOODWILL MEDICAL CLINIC, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080A0000X	Pediatric Adolescent Medicine Physician	A50311	CA
2	207Q00000X	Family Medicine Physician	A50311	CA

General Provider Information

NPI Number	:	1669836946
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOODWILL MEDICAL CLINIC, INC.

Provider Business Mailing Address
First Line	:	2011 BEVERLY BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90057-2403
Country	:	US
Telephone Number	:	213-412-4777
Fax Number	:	213-416-4478

Provider Business Practice Location Address
First Line	:	2011 BEVERLY BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90057-2403
Country	:	US
Telephone Number	:	213-412-4777
Fax Number	:	213-416-4478

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

Provider Enumeration Date	:	04/12/2016
Last Update Date	:	05/16/2016

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