Healthcare Provider Details

I. General information

NPI: 1558386508
Provider Name (Legal Business Name): PETER J GELESKO DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 03/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2820 NILES RD
SAINT JOSEPH MI
49085-3355
US

IV. Provider business mailing address

1562 S TEAKWOOD DR
STEVENSVILLE MI
49127-9659
US

V. Phone/Fax

Practice location:
  • Phone: 269-429-1982
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number2301009165
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: