Provider Demographics
NPI:1336272756
Name:GOODMAN, KENNETH REED (DC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:REED
Last Name:GOODMAN
Suffix:
Gender:M
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:PO BOX 1206
Mailing Address - Street 2:
Mailing Address - City:THATCHER
Mailing Address - State:AZ
Mailing Address - Zip Code:85552
Mailing Address - Country:US
Mailing Address - Phone:928-348-8997
Mailing Address - Fax:928-428-8704
Practice Address - Street 1:3910 W MAIN STREET
Practice Address - Street 2:
Practice Address - City:THATCHER
Practice Address - State:AZ
Practice Address - Zip Code:85552
Practice Address - Country:US
Practice Address - Phone:928-348-8997
Practice Address - Fax:928-348-9088
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5239111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZU50141Medicare UPIN
AZ62067Medicare ID - Type UnspecifiedMEDICARE IDENTIFICATION #