Provider Demographics
NPI:1093993156
Name:GOULART FAMILY CHIROPRACTIC INC
Entity Type:Organization
Organization Name:GOULART FAMILY CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOULART
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:541-388-3588
Mailing Address - Street 1:424 NE FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4919
Mailing Address - Country:US
Mailing Address - Phone:541-388-3588
Mailing Address - Fax:541-388-0839
Practice Address - Street 1:424 NE FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4919
Practice Address - Country:US
Practice Address - Phone:541-388-3588
Practice Address - Fax:541-388-0839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR116939Medicare PIN