MEDICARE: GORLESKY BACK & NECK CHIROPRACTIC, INC

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	261Q00000X	Clinic/Center	1030	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	08452	OTHER	NC	BLUE CROSS-BLUE SHIELD

General Provider Information

NPI Number	:	1013086909
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GORLESKY BACK & NECK CHIROPRACTIC, INC

Provider Business Mailing Address
First Line	:	301 S WHITE ST
Second Line	:
City	:	WAKE FOREST
State	:	NC
Zip	:	27587-2916
Country	:	US
Telephone Number	:	919-556-1033
Fax Number	:	919-556-1034

Provider Business Practice Location Address
First Line	:	301 S WHITE ST
Second Line	:
City	:	WAKE FOREST
State	:	NC
Zip	:	27587-2916
Country	:	US
Telephone Number	:	919-556-1033
Fax Number	:	919-556-1034

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JACK GORLESKY
Credential	:	DC
Telephone Number	:	919-556-1033

Provider Enumeration Date	:	11/07/2006
Last Update Date	:	08/22/2020

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