=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932538923
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOODELL CHIROPRACTIC OFFICE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2013
-----------------------------------------------------
Last Update Date | 11/11/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8020 DURAND AVE
-----------------------------------------------------
City | STURTEVANT
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53177-1976
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-886-8600
-----------------------------------------------------
Fax | 262-886-5342
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8020 DURAND AVE PO BOX 392
-----------------------------------------------------
City | STURTEVANT
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53177-1976
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-886-8600
-----------------------------------------------------
Fax | 262-886-5342
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GARY GOODELL
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 262-886-8600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 224512
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------