=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639272990
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GELESKO CHIROPRACTIC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2006
-----------------------------------------------------
Last Update Date | 03/20/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2820 NILES RD
-----------------------------------------------------
City | SAINT JOSEPH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49085-3355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-429-1982
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1562 S TEAKWOOD DR
-----------------------------------------------------
City | STEVENSVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49127-9659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. PETER JOHN GELESKO
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 269-429-1982
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NS0005X
-----------------------------------------------------
Taxonomy Name | Sports Physician Chiropractor
-----------------------------------------------------
License Number | 23010091165
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------