Provider Demographics
NPI:1952328692
Name:GOFORTH, PHILLIP DARIN (DC)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:DARIN
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 1:826 HIGHWAY 60
Mailing Address - Street 2:
Mailing Address - City:SOCORRO
Mailing Address - State:NM
Mailing Address - Zip Code:87801-3919
Mailing Address - Country:US
Mailing Address - Phone:505-835-9288
Mailing Address - Fax:505-835-2209
Practice Address - Street 1:826 HIGHWAY 60
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801-3919
Practice Address - Country:US
Practice Address - Phone:505-835-9288
Practice Address - Fax:505-835-2209
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1388111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMU61447Medicare UPIN