Healthcare Provider Details

I. General information

NPI: 1245407709
Provider Name (Legal Business Name): KIMBERLY ROCHELLE GORDON SURGICAL ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2008
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3002 GILL ST STE 3
BLOOMINGTON IL
61704-3438
US

IV. Provider business mailing address

1213 RIVIERA DR
BLOOMINGTON IL
61701-7309
US

V. Phone/Fax

Practice location:
  • Phone: 309-846-4716
  • Fax:
Mailing address:
  • Phone: 309-242-6439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: