Provider Demographics
NPI:1043031933
Name:IRON OAK PHYSICAL THERAPY AND PERFORMANCE LLC KYLE GOODWIN SOLE MBR
Entity type:Organization
Organization Name:IRON OAK PHYSICAL THERAPY AND PERFORMANCE LLC KYLE GOODWIN SOLE MBR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:443-366-4757
Mailing Address - Street 1:156 SECRETARIAT DR
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-1786
Mailing Address - Country:US
Mailing Address - Phone:443-366-4757
Mailing Address - Fax:
Practice Address - Street 1:624 INNOVATION DR STE 105
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-3867
Practice Address - Country:US
Practice Address - Phone:443-366-4757
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-23
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy