Healthcare Provider Details

I. General information

NPI: 1720901960
Provider Name (Legal Business Name): GRACE SPINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7685 103RD ST STE 101
JACKSONVILLE FL
32210-9325
US

IV. Provider business mailing address

27 WALNUT KNOLL CT
SAINT CHARLES MO
63304-4549
US

V. Phone/Fax

Practice location:
  • Phone: 314-629-5794
  • Fax:
Mailing address:
  • Phone: 314-629-5794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. JASON COREY GOODMAN
Title or Position: OWNER
Credential: DC
Phone: 314-629-5794