Provider Demographics
NPI:1538639620
Name:THE GOOD PLACE NW, INC
Entity Type:Organization
Organization Name:THE GOOD PLACE NW, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLINT
Authorized Official - Middle Name:
Authorized Official - Last Name:WISSINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-877-8902
Mailing Address - Street 1:960 BROADWAY ST NE STE 1
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-1275
Mailing Address - Country:US
Mailing Address - Phone:503-967-6638
Mailing Address - Fax:503-339-7038
Practice Address - Street 1:960 BROADWAY ST NE STE 1
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-1275
Practice Address - Country:US
Practice Address - Phone:503-967-6638
Practice Address - Fax:503-339-7038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-30
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR=========OtherCHIROPRACTIC