Provider Demographics
NPI:1750445821
Name:GORDON, BRIAN (DC, LAC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:DC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:
Practice Address - Street 1:5363 BALBOA BLVD
Practice Address - Street 2:SUITE 436
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-2805
Practice Address - Country:US
Practice Address - Phone:818-386-8835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC-29620111N00000X
CAAC-13010171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC29620OtherMEDICARE PTAN
CAV06023Medicare UPIN