Healthcare Provider Details

I. General information

NPI: 1396132320
Provider Name (Legal Business Name): BRENDA GORDON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2015
Last Update Date: 04/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3983 LAVISTA RD SUITE 164
TUCKER GA
30084-5153
US

IV. Provider business mailing address

2109 RUTHERFORD GLEN CIR
ATLANTA GA
30340-3878
US

V. Phone/Fax

Practice location:
  • Phone: 404-861-0807
  • Fax:
Mailing address:
  • Phone: 404-861-0807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number059684695
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: