Healthcare Provider Details

I. General information

NPI: 1013521178
Provider Name (Legal Business Name): GORDRELL ENTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2020
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5150 E MAIN ST STE 104
COLUMBUS OH
43213-2441
US

IV. Provider business mailing address

5150 E MAIN ST
COLUMBUS OH
43213-2441
US

V. Phone/Fax

Practice location:
  • Phone: 614-604-2274
  • Fax:
Mailing address:
  • Phone: 614-604-8274
  • Fax: 614-604-8276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name: TOMIKA GORDON
Title or Position: MANAGING MEMBER
Credential:
Phone: 614-946-5504