Provider Demographics
NPI:1306330345
Name:KINGWOOD FAMILY CARE, LLC
Entity type:Organization
Organization Name:KINGWOOD FAMILY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:304-319-1825
Mailing Address - Street 1:17548 VETERANS MEMORIAL HIGHWAY
Mailing Address - Street 2:SUITE D
Mailing Address - City:KINGWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26537
Mailing Address - Country:US
Mailing Address - Phone:304-441-2001
Mailing Address - Fax:304-441-2009
Practice Address - Street 1:17548 VETERANS MEMORIAL HIGHWAY
Practice Address - Street 2:SUITE D
Practice Address - City:KINGWOOD
Practice Address - State:WV
Practice Address - Zip Code:26537
Practice Address - Country:US
Practice Address - Phone:304-441-2001
Practice Address - Fax:304-441-2009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVUD000764150001261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care