Provider Demographics
NPI:1336884659
Name:AS GORDON ENTERPRISE LLC
Entity Type:Organization
Organization Name:AS GORDON ENTERPRISE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AVERILL
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:904-477-3853
Mailing Address - Street 1:1282 CHESTERFIELD LN
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-3797
Mailing Address - Country:US
Mailing Address - Phone:904-477-3853
Mailing Address - Fax:
Practice Address - Street 1:102 CENTER ST
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-1533
Practice Address - Country:US
Practice Address - Phone:904-477-3853
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-02
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center