MEDICARE: JORDAN GOSZTOLA

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	390200000X	Student in an Organized Health Care Education/Training Program		IN

General Provider Information

NPI Number	:	1245601483
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN GOSZTOLA

Provider Business Mailing Address
First Line	:	1900 W JACKSON ST
Second Line	:
City	:	MUNCIE
State	:	IN
Zip	:	47303-4854
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2000 W UNIVERSITY AVE
Second Line	:	HEALTH AND PHYSICAL ACTIVITY BUILDING
City	:	MUNCIE
State	:	IN
Zip	:	47306-1022
Country	:	US
Telephone Number	:	765-285-3223
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/14/2015
Last Update Date	:	10/14/2015

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