Healthcare Provider Details

I. General information

NPI: 1275991341
Provider Name (Legal Business Name): JASON GO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2016
Last Update Date: 02/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 STONE ST SUITE 3
PORT HURON MI
48060-3563
US

IV. Provider business mailing address

863 RIVERVIEW LN
MARYSVILLE MI
48040-1507
US

V. Phone/Fax

Practice location:
  • Phone: 312-622-3659
  • Fax:
Mailing address:
  • Phone: 312-622-3659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number54010000157
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: