MEDICARE: DOMINIQUE MCGORDON

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	253Z00000X	In Home Supportive Care Agency	23-015658-1	IN

General Provider Information

NPI Number	:	1336920867
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIQUE MCGORDON

Provider Business Mailing Address
First Line	:	4837 OAKBROOK DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46254-1117
Country	:	US
Telephone Number	:	317-903-3007
Fax Number	:	463-900-1728

Provider Business Practice Location Address
First Line	:	4837 OAKBROOK DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46254-1117
Country	:	US
Telephone Number	:	317-903-3007
Fax Number	:	463-900-1728

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

Provider Enumeration Date	:	10/10/2023
Last Update Date	:	10/10/2023

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Directions to “ DOMINIQUE MCGORDON ” Practice Location

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