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General NPI Number Information
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NPI Number | 1891818548
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Entity Type | Organization
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Legal Business Name | GORDON FAMILY CHIROPRACTIC, L.L.C.
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Dates
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Enumeration Date | 04/09/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 105 E. 51ST. STREET
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City | CHICAGO
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State | IL
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Zip | 60615
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Country | US
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Telephone | 773-318-7704
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Fax |
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Provider Business Mailing Address
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Address Line | 4730 S PRAIRIE AVE
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City | CHICAGO
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State | IL
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Zip | 60615-1206
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Country | US
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Telephone | 773-548-6761
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Fax |
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | DR. AYO HENRY GORDON
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Credential | D.C.
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Telephone | 773-318-7704
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number |
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License Number State | IL
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