MEDICARE: DR. WAYNE GORDON D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	CHIR008143	GA
2	111NR0400X	Rehabilitation Chiropractor	CHIR008143	GA
3	111N00000X	Chiropractor	CH9576	FL

General Provider Information

NPI Number	:	1003952573
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WAYNE GORDON D.C.

Provider Business Mailing Address
First Line	:	228 PONTE VEDRA PARK DR
Second Line	:	SUITE 800
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32082-6613
Country	:	US
Telephone Number	:	904-418-3937
Fax Number	:

Provider Business Practice Location Address
First Line	:	228 PONTE VEDRA PARK DR
Second Line	:	SUITE 800
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32082-6613
Country	:	US
Telephone Number	:	904-418-3937
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	01/26/2017

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