Provider Demographics
NPI:1700364767
Name:GOODELL, AUSTIN J (DC)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:J
Last Name:GOODELL
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 1:1519 S RESERVE ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-4755
Mailing Address - Country:US
Mailing Address - Phone:406-549-2006
Mailing Address - Fax:406-549-6574
Practice Address - Street 1:1519 S RESERVE ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-4755
Practice Address - Country:US
Practice Address - Phone:406-549-2006
Practice Address - Fax:406-549-6574
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTCHI-CHI-LIC-5142111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty