=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730959610
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAMERON GORDINEER DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2024
-----------------------------------------------------
Last Update Date | 01/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4949 AUTUMN OAKS DR STE A
-----------------------------------------------------
City | MARYVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62062-8557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-774-6252
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 269 HARBOR MILL DR
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62294-3241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-578-3868
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 038.014100
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------