=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942858329
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GEORGE GORDON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2019
-----------------------------------------------------
Last Update Date | 08/29/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4895 WINDWARD PASSAGE DR STE 6
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33436-7741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-877-8753
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4895 WINDWARD PASSAGE DR STE 6
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33436-7741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-877-8753
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 405300000X
-----------------------------------------------------
Taxonomy Name | Prevention Professional
-----------------------------------------------------
License Number | 00000
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------