Provider Demographics
NPI:1376687210
Name:GOODWIN, GWYNDOLYN B (DC)
Entity Type:Individual
Prefix:DR
First Name:GWYNDOLYN
Middle Name:B
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 S PARK ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3825
Mailing Address - Country:US
Mailing Address - Phone:678-485-3155
Mailing Address - Fax:
Practice Address - Street 1:775 S PARK ST
Practice Address - Street 2:SUITE 102
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3825
Practice Address - Country:US
Practice Address - Phone:678-485-3155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR384111N00000X
GACHIRO07391111NP0017X, 111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111N00000XChiropractic ProvidersChiropractor
No111NP0017XChiropractic ProvidersChiropractorPediatric Chiropractor