MEDICARE: KERRY GORDON MS, ATC, CSCS

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	174400000X	Specialist	660	SC
2	174400000X	Specialist	0506182	NV

General Provider Information

NPI Number	:	1639358831
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KERRY GORDON MS, ATC, CSCS

Provider Business Mailing Address
First Line	:	6775 EDMOND ST STE 300
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89118-3502
Country	:	US
Telephone Number	:	702-205-1315
Fax Number	:

Provider Business Practice Location Address
First Line	:	980 KELLY JOHNSON DR
Second Line	:	SUITE 200
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-3785
Country	:	US
Telephone Number	:	702-205-1315
Fax Number	:

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

Provider Enumeration Date	:	10/24/2007
Last Update Date	:	04/23/2019

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