Provider Demographics
NPI:1598833287
Name:GOFORTH, FORREST WAYNE (DC)
Entity Type:Individual
Prefix:DR
First Name:FORREST
Middle Name:WAYNE
Last Name:GOFORTH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 W HILL AVE
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-6218
Mailing Address - Country:US
Mailing Address - Phone:505-722-9002
Mailing Address - Fax:505-722-7031
Practice Address - Street 1:108 W HILL AVE
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-6218
Practice Address - Country:US
Practice Address - Phone:505-722-9002
Practice Address - Fax:505-722-7031
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM06-00001390111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNMA101797OtherMEDICARE ID
NM608817900OtherFED WORKER'S COMP
NMT40918Medicare UPIN