Provider Demographics
NPI:1699795492
Name:GOSS CHIROPRACTIC CLINIC AND REHABILITATION CENTER
Entity type:Organization
Organization Name:GOSS CHIROPRACTIC CLINIC AND REHABILITATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:WILLIS
Authorized Official - Last Name:GOSS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:570-829-5888
Mailing Address - Street 1:1498 SANS SOUCI PARKWAY
Mailing Address - Street 2:
Mailing Address - City:HANOVER TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18706
Mailing Address - Country:US
Mailing Address - Phone:570-829-5888
Mailing Address - Fax:570-970-2757
Practice Address - Street 1:1498 SANS SOUCI PARKWAY
Practice Address - Street 2:
Practice Address - City:HANOVER TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18706
Practice Address - Country:US
Practice Address - Phone:570-829-5888
Practice Address - Fax:570-970-2757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC5357L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014723000002Medicaid
U50378Medicare UPIN
PA0014723000002Medicaid