Provider Demographics
NPI:1053635839
Name:GOFORTH CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:GOFORTH CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:DARIN
Authorized Official - Last Name:GOFORTH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:575-835-9288
Mailing Address - Street 1:826 HIGHWAY 60
Mailing Address - Street 2:
Mailing Address - City:SOCORRO
Mailing Address - State:NM
Mailing Address - Zip Code:87801-3919
Mailing Address - Country:US
Mailing Address - Phone:575-835-9288
Mailing Address - Fax:575-835-2209
Practice Address - Street 1:826 HIGHWAY 60
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801-3919
Practice Address - Country:US
Practice Address - Phone:575-835-9288
Practice Address - Fax:575-835-2209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-23
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1388111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty