=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124308952
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOODSPINE PLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2011
-----------------------------------------------------
Last Update Date | 10/30/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 S 11TH ST
-----------------------------------------------------
City | COLLINSVILLE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74021-3128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 991-837-1284
-----------------------------------------------------
Fax | 918-553-8802
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 877
-----------------------------------------------------
City | SKIATOOK
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74070-0877
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-371-2848
-----------------------------------------------------
Fax | 918-553-8802
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JAKE W LANDRETH
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 918-521-8888
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 4002
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------