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General NPI Number Information
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NPI Number | 1669305645
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Entity Type | Organization
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Legal Business Name | CREATE YOUR OWN LEGACY EMPOWERMENT GROUP
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Dates
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Enumeration Date | 06/08/2026
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Last Update Date | 06/08/2026
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Provider Practice Location Address
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Address Line | 16316 OLD STONE CROSSING DR
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City | CHARLOTTE
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State | NC
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Zip | 28213-4923
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Country | US
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Telephone | 216-501-9618
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Fax |
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Provider Business Mailing Address
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Address Line | 16316 OLD STONE CROSSING DR
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City | CHARLOTTE
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State | NC
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Zip | 28213-4923
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Country | US
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Telephone | 216-501-9618
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DAMON L GORDON
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Credential |
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Telephone | 216-501-9618
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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