Provider Demographics
NPI:1508304783
Name:GORDON FAMILY CHIROPRACTIC INC
Entity Type:Organization
Organization Name:GORDON FAMILY CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:904-418-3937
Mailing Address - Street 1:228 PONTE VEDRA PARK DR
Mailing Address - Street 2:SUITE 800
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32082-6613
Mailing Address - Country:US
Mailing Address - Phone:904-418-3937
Mailing Address - Fax:
Practice Address - Street 1:228 PONTE VEDRA PARK DR
Practice Address - Street 2:SUITE 800
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32082-6613
Practice Address - Country:US
Practice Address - Phone:904-418-3937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-07
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9576111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty