Provider Demographics
NPI:1629271846
Name:BRIAN GORDON DC LAC ACUPUNCTURE PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:BRIAN GORDON DC LAC ACUPUNCTURE PROFESSIONAL CORPORATION
Other - Org Name:ACTIVE CARE SPINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:BERNARD
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:DC, LAC
Authorized Official - Phone:818-386-8835
Mailing Address - Street 1:5363 BALBOA BLVD STE 436
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-2840
Mailing Address - Country:US
Mailing Address - Phone:818-386-8835
Mailing Address - Fax:818-387-6142
Practice Address - Street 1:5363 BALBOA BLVD
Practice Address - Street 2:SUITE #439
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-2805
Practice Address - Country:US
Practice Address - Phone:818-401-3295
Practice Address - Fax:818-387-6142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC-29620111N00000X
CAAC-13010171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC29620OtherMEDICARE PTAN
CADC29620OtherMEDICARE PTAN