Provider Demographics
NPI:1043407919
Name:GOFORTH CHIROPRACTIC LIFE CENTER, P.C.
Entity type:Organization
Organization Name:GOFORTH CHIROPRACTIC LIFE CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR/OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:FORREST
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:GOFORTH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:505-722-9002
Mailing Address - Street 1:108 W HILL AVE
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-6218
Mailing Address - Country:US
Mailing Address - Phone:505-722-9002
Mailing Address - Fax:505-722-7031
Practice Address - Street 1:108 W HILL AVE
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-6218
Practice Address - Country:US
Practice Address - Phone:505-722-9002
Practice Address - Fax:505-722-7031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM433111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMT40198Medicare UPIN
NM2670140Medicare PIN