Healthcare Provider Details

I. General information

NPI: 1629271846
Provider Name (Legal Business Name): BRIAN GORDON DC LAC ACUPUNCTURE PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 06/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5363 BALBOA BLVD SUITE #439
ENCINO CA
91316-2805
US

IV. Provider business mailing address

5363 BALBOA BLVD STE 436
ENCINO CA
91316-2840
US

V. Phone/Fax

Practice location:
  • Phone: 818-401-3295
  • Fax: 818-387-6142
Mailing address:
  • Phone: 818-386-8835
  • Fax: 818-387-6142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC-29620
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC-13010
License Number StateCA

VIII. Authorized Official

Name: DR. BRIAN BERNARD GORDON
Title or Position: PRESIDENT
Credential: DC, LAC
Phone: 818-386-8835