Healthcare Provider Details

I. General information

NPI: 1619638186
Provider Name (Legal Business Name): ELJIN JON GORMAN MS LAT ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2022
Last Update Date: 01/06/2022
Certification Date: 01/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2004 STONE PL
CLOVIS NM
88101-8667
US

IV. Provider business mailing address

2004 STONE PL
CLOVIS NM
88101-8667
US

V. Phone/Fax

Practice location:
  • Phone: 505-903-1661
  • Fax:
Mailing address:
  • Phone: 505-903-1661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT712
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: