Provider Demographics
NPI:1841405743
Name:GORDON, CHARLES ROBERT (MS, ATC, CSCS)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:ROBERT
Last Name:GORDON
Suffix:
Gender:M
Credentials:MS, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 2 BOX 223-1
Mailing Address - Street 2:
Mailing Address - City:RED HOUSE
Mailing Address - State:WV
Mailing Address - Zip Code:25168-9663
Mailing Address - Country:US
Mailing Address - Phone:304-550-3499
Mailing Address - Fax:
Practice Address - Street 1:3910 TEAYS VALLEY RD
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9756
Practice Address - Country:US
Practice Address - Phone:304-757-7293
Practice Address - Fax:304-757-0574
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer