Provider Demographics
NPI:1487187936
Name:GORDON, CHAVIS
Entity Type:Individual
Prefix:
First Name:CHAVIS
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3505 N ELIZABETH ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80205-4245
Mailing Address - Country:US
Mailing Address - Phone:804-901-0179
Mailing Address - Fax:
Practice Address - Street 1:3505 N ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-4245
Practice Address - Country:US
Practice Address - Phone:804-901-0179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-11
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver