Provider Demographics
NPI:1457492639
Name:GOODWIN, CHARLES M (DC,LAC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:M
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:DC,LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 DAKOTA AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-6626
Mailing Address - Country:US
Mailing Address - Phone:831-429-1188
Mailing Address - Fax:831-429-1396
Practice Address - Street 1:111 DAKOTA AVE STE 2
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-6626
Practice Address - Country:US
Practice Address - Phone:831-429-1188
Practice Address - Fax:831-429-1396
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC17690111N00000X
CAAC6842171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111N00000XChiropractic ProvidersChiropractor
Not Answered171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0176900Medicare ID - Type Unspecified