1891904579 NPI number — GOODWIN COMMUNITY HEALTH CENTER

Table of content: (NPI 1891904579)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891904579 NPI number — GOODWIN COMMUNITY HEALTH CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOODWIN COMMUNITY HEALTH CENTER
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:
COASTAL MEDICAL ACCESS PROJECT
Provider Other Organization Name Type Code:
3
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:
1891904579
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 LAKESHORE DR
Provider Second Line Business Mailing Address:
STE E
Provider Business Mailing Address City Name:
SAINT MARYS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31558-3803
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-554-3559
Provider Business Mailing Address Fax Number:
912-554-8344

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3010 HAMPTON AVE
Provider Second Line Business Practice Location Address:
STE 6
Provider Business Practice Location Address City Name:
BRUNSWICK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31520-4224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-466-8909
Provider Business Practice Location Address Fax Number:
912-466-8995
Provider Enumeration Date:
05/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KOTA
Authorized Official First Name:
PATRICIA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
912-554-3559

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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