Provider Demographics
NPI:1508160334
Name:GORDON, SAMUEL LANCE (DC)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:LANCE
Last Name:GORDON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 IH 69 ACCESS RD
Mailing Address - Street 2:M-5
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78410-4542
Mailing Address - Country:US
Mailing Address - Phone:361-241-7451
Mailing Address - Fax:361-241-7452
Practice Address - Street 1:4101 US HIGHWAY 77
Practice Address - Street 2:M-5
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78410-4542
Practice Address - Country:US
Practice Address - Phone:361-241-7451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-09
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11644111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor