Basic Information
| Provider Information | |||||||||
| NPI: | 1932538923 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GOODELL CHIROPRACTIC OFFICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8020 DURAND AVE | ||||||||
| Address2: | PO BOX 392 | ||||||||
| City: | STURTEVANT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531771976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2628868600 | ||||||||
| FaxNumber: | 2628865342 | ||||||||
| Practice Location | |||||||||
| Address1: | 8020 DURAND AVE | ||||||||
| Address2: | |||||||||
| City: | STURTEVANT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531771976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2628868600 | ||||||||
| FaxNumber: | 2628865342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2013 | ||||||||
| LastUpdateDate: | 11/11/2013 | ||||||||
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| AuthorizedOfficialLastName: | GOODELL | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2628868600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 224512 | WI | Y | 193400000X SINGLE SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 38886700 | 05 | WI | MEDICAID | 350024280 | 01 | WI | MEDICARE RAILROAD | OTHER |