Provider Demographics
NPI:1912346354
Name:SAMUEL L GORDON PROFESSIONAL LIMITED LIABILITY COMPANY
Entity type:Organization
Organization Name:SAMUEL L GORDON PROFESSIONAL LIMITED LIABILITY COMPANY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:LANCE
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:361-241-7451
Mailing Address - Street 1:4101 US HIGHWAY 77
Mailing Address - Street 2:M-5
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78410-4542
Mailing Address - Country:US
Mailing Address - Phone:361-241-7451
Mailing Address - Fax:361-241-7452
Practice Address - Street 1:4101 US HIGHWAY 77
Practice Address - Street 2:M-5
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78410-4542
Practice Address - Country:US
Practice Address - Phone:361-241-7451
Practice Address - Fax:361-241-7452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-19
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty