Provider Demographics
NPI:1497087076
Name:KABS GOODWILL, LLC
Entity Type:Organization
Organization Name:KABS GOODWILL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ADETOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:ADEYANJU-ISHOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-420-5885
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:813-420-5885
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:813-420-5885
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-05
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME102530261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain