Provider Demographics
NPI:1063738516
Name:GOODALE, GREG THOMAS (DC)
Entity type:Individual
Prefix:DR
First Name:GREG
Middle Name:THOMAS
Last Name:GOODALE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 W 2ND ST.
Mailing Address - Street 2:PO BOX 369
Mailing Address - City:SCHALLER
Mailing Address - State:IA
Mailing Address - Zip Code:51053-0369
Mailing Address - Country:US
Mailing Address - Phone:712-275-4790
Mailing Address - Fax:712-275-4349
Practice Address - Street 1:204 W. 2ND ST
Practice Address - Street 2:
Practice Address - City:SCHALLER
Practice Address - State:IA
Practice Address - Zip Code:51053-0369
Practice Address - Country:US
Practice Address - Phone:712-275-4790
Practice Address - Fax:712-275-4349
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-08
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA007292111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IB1758OtherMEDICARE PTAN
IAIA19158Medicaid