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General NPI Number Information
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NPI Number | 1043407919
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Entity Type | Organization
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Legal Business Name | GOFORTH CHIROPRACTIC LIFE CENTER, P.C.
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Dates
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Enumeration Date | 09/25/2007
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Last Update Date | 09/25/2007
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Provider Practice Location Address
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Address Line | 108 W HILL AVE
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City | GALLUP
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State | NM
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Zip | 87301-6218
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Country | US
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Telephone | 505-722-9002
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Fax | 505-722-7031
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Provider Business Mailing Address
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Address Line | 108 W HILL AVE
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City | GALLUP
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State | NM
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Zip | 87301-6218
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Country | US
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Telephone | 505-722-9002
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Fax | 505-722-7031
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Authorized Official
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Title or Position | DR/OWNER/OPERATOR
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Name | DR. FORREST WAYNE GOFORTH
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Credential | D.C.
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Telephone | 505-722-9002
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 433
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License Number State | NM
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