1639258676 NPI number — GOODWIN HOUSE INCORPORATED

Table of content: (NPI 1639258676)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639258676 NPI number — GOODWIN HOUSE INCORPORATED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOODWIN HOUSE INCORPORATED
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639258676
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/02/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4800 FILLMORE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALEXANDRIA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22311-5070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-824-1290
Provider Business Mailing Address Fax Number:
703-824-1241

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3440 S JEFFERSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FALLS CHURCH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22041-3145
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-820-1488
Provider Business Practice Location Address Fax Number:
703-824-1241
Provider Enumeration Date:
11/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SIEGEL
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CHIEF BUSINESS DEVELOPMENT OFFICER
Authorized Official Telephone Number:
703-578-7554

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NH2559 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4951719 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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