Provider Demographics
NPI:1184221376
Name:GORDON, DARLENE
Entity Type:Individual
Prefix:
First Name:DARLENE
Middle Name:
Last Name:GORDON
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 1:700 TRAY CT
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-6528
Mailing Address - Country:US
Mailing Address - Phone:404-798-4304
Mailing Address - Fax:912-235-2694
Practice Address - Street 1:9100 WHITE BLUFF RD STE 106
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-4673
Practice Address - Country:US
Practice Address - Phone:912-235-2694
Practice Address - Fax:912-235-2694
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11D2192193291U00000X, 247ZC0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physicianGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical Laboratory