Provider Demographics
NPI:1932538923
Name:GOODELL CHIROPRACTIC OFFICE
Entity type:Organization
Organization Name:GOODELL CHIROPRACTIC OFFICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:262-886-8600
Mailing Address - Street 1:8020 DURAND AVE
Mailing Address - Street 2:PO BOX 392
Mailing Address - City:STURTEVANT
Mailing Address - State:WI
Mailing Address - Zip Code:53177-1976
Mailing Address - Country:US
Mailing Address - Phone:262-886-8600
Mailing Address - Fax:262-886-5342
Practice Address - Street 1:8020 DURAND AVE
Practice Address - Street 2:
Practice Address - City:STURTEVANT
Practice Address - State:WI
Practice Address - Zip Code:53177-1976
Practice Address - Country:US
Practice Address - Phone:262-886-8600
Practice Address - Fax:262-886-5342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-11
Last Update Date:2013-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI224512111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38886700Medicaid
WI350024280OtherMEDICARE RAILROAD
WI38886700Medicaid