MEDICARE: TERRA DENEAN 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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1548825664
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERRA DENEAN GORDON

Provider Business Mailing Address
First Line	:	4650 W OAKEY BLVD APT 2198
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-1542
Country	:	US
Telephone Number	:	925-305-0267
Fax Number	:

Provider Business Practice Location Address
First Line	:	4650 W OAKEY BLVD APT 2198
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-1542
Country	:	US
Telephone Number	:	925-305-0267
Fax Number	:

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

Provider Enumeration Date	:	05/03/2019
Last Update Date	:	05/03/2019

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Directions to “ TERRA DENEAN GORDON ” Practice Location

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