Provider Demographics
NPI:1740221852
Name:GOODWIN, LANCE BRANDON (DC)
Entity Type:Individual
Prefix:DR
First Name:LANCE
Middle Name:BRANDON
Last Name:GOODWIN
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:PO BOX 172
Mailing Address - Street 2:
Mailing Address - City:CATOOSA
Mailing Address - State:OK
Mailing Address - Zip Code:74015-0172
Mailing Address - Country:US
Mailing Address - Phone:918-266-6000
Mailing Address - Fax:918-266-6002
Practice Address - Street 1:2865 E SKELLY DR STE 200
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-6219
Practice Address - Country:US
Practice Address - Phone:918-266-6000
Practice Address - Fax:918-266-6002
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3511111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK800522061Medicare ID - Type UnspecifiedGROUP/CLINIC PROVIDER NUM
OKU90113Medicare UPIN