Provider Demographics
NPI:1124308952
Name:GOODSPINE PLC
Entity type:Organization
Organization Name:GOODSPINE PLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAKE
Authorized Official - Middle Name:W
Authorized Official - Last Name:LANDRETH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:918-521-8888
Mailing Address - Street 1:PO BOX 877
Mailing Address - Street 2:
Mailing Address - City:SKIATOOK
Mailing Address - State:OK
Mailing Address - Zip Code:74070-0877
Mailing Address - Country:US
Mailing Address - Phone:918-371-2848
Mailing Address - Fax:918-553-8802
Practice Address - Street 1:111 S 11TH ST
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:OK
Practice Address - Zip Code:74021-3128
Practice Address - Country:US
Practice Address - Phone:991-837-1284
Practice Address - Fax:918-553-8802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-24
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4002261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center