Provider Demographics
NPI:1225354822
Name:KABS GOODWILL, LLC
Entity Type:Organization
Organization Name:KABS GOODWILL, LLC
Other - Org Name:BEARSS MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BODE
Authorized Official - Middle Name:
Authorized Official - Last Name:ISHOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-977-7804
Mailing Address - Street 1:2806 E BEARSS AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-2653
Mailing Address - Country:US
Mailing Address - Phone:813-977-7804
Mailing Address - Fax:
Practice Address - Street 1:2806 E BEARSS AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-2653
Practice Address - Country:US
Practice Address - Phone:813-977-7804
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEARRS MEDICAL CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-08
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME102530208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty