Provider Demographics
NPI:1275706046
Name:GOODWIN, RICHARD LEWIS
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:LEWIS
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 S 74TH ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-4136
Mailing Address - Country:US
Mailing Address - Phone:602-332-6267
Mailing Address - Fax:
Practice Address - Street 1:1710 S 74TH ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-4136
Practice Address - Country:US
Practice Address - Phone:602-332-6267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-11
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5102174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ5102OtherPROFESSIONA FOSTER HOME