=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912186412
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK THOMAS GOODMAN DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2007
-----------------------------------------------------
Last Update Date | 04/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3421 KITSAP WAY SUITE B
-----------------------------------------------------
City | BREMERTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98312-2601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-377-1626
-----------------------------------------------------
Fax | 360-377-1903
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3421 KITSAP WAY SUITE B
-----------------------------------------------------
City | BREMERTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98312-2601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-377-1626
-----------------------------------------------------
Fax | 360-377-1903
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH00002820
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------