MEDICARE: CHAVIS GORDON

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	172A00000X	Driver

General Provider Information

NPI Number	:	1487187936
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHAVIS GORDON

Provider Business Mailing Address
First Line	:	3505 N ELIZABETH ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80205-4245
Country	:	US
Telephone Number	:	804-901-0179
Fax Number	:

Provider Business Practice Location Address
First Line	:	3505 N ELIZABETH ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80205-4245
Country	:	US
Telephone Number	:	804-901-0179
Fax Number	:

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

Provider Enumeration Date	:	04/11/2017
Last Update Date	:	04/11/2017

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Directions to “ CHAVIS GORDON ” Practice Location

Language	Start Address	Practice Location

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