Healthcare Provider Details

I. General information

NPI: 1598833287
Provider Name (Legal Business Name): FORREST WAYNE GOFORTH DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 06/08/2012
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 Number06-00001390
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: