MEDICARE: DR. JACK WILLIAM GOSS DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	2301010811	MI

General Provider Information

NPI Number	:	1760046544
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK WILLIAM GOSS DC

Provider Business Mailing Address
First Line	:	5600 METROPOLITAN PKWY
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48310-4107
Country	:	US
Telephone Number	:	586-264-2100
Fax Number	:

Provider Business Practice Location Address
First Line	:	5600 METROPOLITAN PKWY
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48310-4107
Country	:	US
Telephone Number	:	586-264-2100
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/26/2019
Last Update Date	:	04/26/2019

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