Basic Information
| Provider Information | |||||||||
| NPI: | 1750484978 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODWIN | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | MATTHEW | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12952 BANDERA RD | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | HELOTES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780234689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103729600 | ||||||||
| FaxNumber: | 2103720211 | ||||||||
| Practice Location | |||||||||
| Address1: | 12952 BANDERA RD | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | HELOTES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780234689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103729600 | ||||||||
| FaxNumber: | 2103720211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 04/29/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1079754 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251S0007X | 1079754 | TX | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports | 2251X0800X | 1079754 | TX | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
ID Information
| ID | Type | State | Issuer | Description | 8T4082 | 01 | TX | BCBS INDIVIDUAL | OTHER |