Provider Demographics
NPI:1801920657
Name:GODSEY, STACY ALLEN (DC)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:ALLEN
Last Name:GODSEY
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 1:4505 TROUP HWY
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703
Mailing Address - Country:US
Mailing Address - Phone:903-509-9990
Mailing Address - Fax:903-509-3390
Practice Address - Street 1:4505 TROUP HWY
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703
Practice Address - Country:US
Practice Address - Phone:903-509-9990
Practice Address - Fax:903-509-3390
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9796111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXV02343Medicare UPIN
TX8C8247Medicare ID - Type Unspecified