Healthcare Provider Details

I. General information

NPI: 1043407919
Provider Name (Legal Business Name): GOFORTH CHIROPRACTIC LIFE CENTER, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2007
Last Update Date: 09/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 W HILL AVE
GALLUP NM
87301-6218
US

IV. Provider business mailing address

108 W HILL AVE
GALLUP NM
87301-6218
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-9002
  • Fax: 505-722-7031
Mailing address:
  • Phone: 505-722-9002
  • Fax: 505-722-7031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number433
License Number StateNM

VIII. Authorized Official

Name: DR. FORREST WAYNE GOFORTH
Title or Position: DR/OWNER/OPERATOR
Credential: D.C.
Phone: 505-722-9002