Provider Demographics
NPI:1932610011
Name:GOODIN, KENNETH M (DPT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
Last Name:GOODIN
Suffix:
Gender:M
Credentials:DPT
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 117345
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-7345
Mailing Address - Country:US
Mailing Address - Phone:904-346-3465
Mailing Address - Fax:904-858-6489
Practice Address - Street 1:14985 OLD SAINT AUGUSTINE RD UNIT 106
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-9478
Practice Address - Country:US
Practice Address - Phone:904-288-9491
Practice Address - Fax:904-288-9698
Is Sole Proprietor?:No
Enumeration Date:2017-10-17
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTT33065225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist