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General NPI Number Information
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NPI Number | 1053724203
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Entity Type | Organization
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Legal Business Name | RENEE GORDON LLC
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Dates
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Enumeration Date | 06/05/2014
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Last Update Date | 06/05/2014
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Provider Practice Location Address
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Address Line | 2405 ASHFORD DR
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City | ALBANY
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State | GA
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Zip | 31721-9246
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Country | US
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Telephone | 229-344-6117
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Fax |
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Provider Business Mailing Address
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Address Line | 2405 ASHFORD DR
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City | ALBANY
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State | GA
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Zip | 31721-9246
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Country | US
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Telephone | 229-344-6117
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | RENEE CANDACE AHLMARK-GORDON
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Credential | OD
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Telephone | 229-344-6117
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPT002136
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License Number State | GA
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