1548439185 NPI number — LYNN E GOODWIN OD PC

Table of content: (NPI 1548439185)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548439185 NPI number — LYNN E GOODWIN OD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LYNN E GOODWIN OD PC
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:
1548439185
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/23/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
04/11/2024
NPI Reactivation Date:
05/01/2024

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6006
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MYRTLE CREEK
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97457-0056
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-863-5258
Provider Business Mailing Address Fax Number:
541-863-6000

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
425 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MYRTLE CREEK
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97457-0056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-863-5258
Provider Business Practice Location Address Fax Number:
541-863-6000
Provider Enumeration Date:
02/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GOODWIN
Authorized Official First Name:
LYNN
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
541-863-5258

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1481ATI , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 22617-5 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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