Healthcare Provider Details

I. General information

NPI: 1457355398
Provider Name (Legal Business Name): GORDON LESLIE STEPHENSON JR. D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1714 MANCHESTER EXPY
COLUMBUS GA
31904-6748
US

IV. Provider business mailing address

1714 MANCHESTER EXPY
COLUMBUS GA
31904-6748
US

V. Phone/Fax

Practice location:
  • Phone: 706-596-0909
  • Fax: 706-596-0919
Mailing address:
  • Phone: 706-596-0909
  • Fax: 706-596-0919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0005828
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: