MEDICARE: DR. JACK GORLESKY DC

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	111N00000X	Chiropractor	1030	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	08452	OTHER	NC	BC/BS

General Provider Information

NPI Number	:	1528027570
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK GORLESKY DC

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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/20/2006
Last Update Date	:	07/08/2007

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