Provider Demographics
NPI:1639258676
Name:GOODWIN HOUSE INCORPORATED
Entity Type:Organization
Organization Name:GOODWIN HOUSE INCORPORATED
Other - Org Name:GOODWIN HOUSE BAILEY'S CROSSROADS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:T
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:703-824-1355
Mailing Address - Street 1:4800 FILLMORE AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22311-5070
Mailing Address - Country:US
Mailing Address - Phone:703-824-1290
Mailing Address - Fax:703-824-1241
Practice Address - Street 1:4800 FILLMORE AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22311-5070
Practice Address - Country:US
Practice Address - Phone:703-824-1290
Practice Address - Fax:703-824-1241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VANH2559314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4951719Medicaid
VA495171Medicare ID - Type UnspecifiedGHBC MCA PROVIDER NO.