Provider Demographics
NPI:1003313842
Name:GOSS, MACKENZIE KATE
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:KATE
Last Name:GOSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5600 METROPOLITAN PKWY
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-4107
Mailing Address - Country:US
Mailing Address - Phone:586-264-2100
Mailing Address - Fax:586-264-1117
Practice Address - Street 1:5600 METROPOLITAN PKWY
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-4107
Practice Address - Country:US
Practice Address - Phone:586-264-2100
Practice Address - Fax:586-264-1117
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010664111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor