Healthcare Provider Details

I. General information

NPI: 1528831997
Provider Name (Legal Business Name): GORDON FLANNIGAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2023
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 FLEMING FALLS RD
MANSFIELD OH
44905-1341
US

IV. Provider business mailing address

1160 FLEMING FALLS RD
MANSFIELD OH
44905-1341
US

V. Phone/Fax

Practice location:
  • Phone: 419-631-2886
  • Fax:
Mailing address:
  • Phone: 419-631-2886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License NumberRQ953947
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberRQ953947
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: