Provider Demographics
NPI:1003371063
Name:GORDON PERFORMANCE ACUPUNCTURE, PLLC
Entity Type:Organization
Organization Name:GORDON PERFORMANCE ACUPUNCTURE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:505-603-7790
Mailing Address - Street 1:4420 ASTER LN
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-7874
Mailing Address - Country:US
Mailing Address - Phone:505-603-7790
Mailing Address - Fax:
Practice Address - Street 1:120 S BEAVER ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-5602
Practice Address - Country:US
Practice Address - Phone:505-603-7790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty