Healthcare Provider Details

I. General information

NPI: 1942692769
Provider Name (Legal Business Name): CHARLES GORDON P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2015
Last Update Date: 03/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 CENTER ST STE 1
GOFFSTOWN NH
03045-2948
US

IV. Provider business mailing address

32 WILDWOOD RD
AUBURN NH
03032-3750
US

V. Phone/Fax

Practice location:
  • Phone: 603-497-4871
  • Fax:
Mailing address:
  • Phone: 603-623-3109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2555
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: