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General NPI Number Information
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NPI Number | 1952742017
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Entity Type | Individual
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Provider Name | JEREMY GONSOWSKI DC
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Gender | Male
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Dates
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Enumeration Date | 07/17/2013
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Last Update Date | 07/17/2013
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Provider Practice Location Address
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Address Line | 1750 HIGHWAY 192 W SUITE 4
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City | LONDON
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State | KY
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Zip | 40741-2639
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Country | US
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Telephone | 606-878-0088
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 593
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City | BEREA
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State | KY
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Zip | 40403-0593
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Country | US
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Telephone | 606-878-0088
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 5397
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License Number State | KY
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