Organization · NPI-2

As Gordon Enterprise LLC

Clinic/Center · Grayslake, IL

NPI number1336884659
StatusActive
Last updated in NPPESMay 2, 2022

Details

NPI
1336884659
Entity type
Organization (NPI-2)
Legal business name
As Gordon Enterprise LLC
Organization subpart
No
Enumeration date
May 2, 2022
Certification date
May 2, 2022
Last updated
May 2, 2022

Taxonomy and licenses

Taxonomy codeDescriptionLicenseStatePrimary
261Q00000X Clinic/Center––Yes

Practice location

102 Center St
Grayslake, IL 60030-1533

Phone 904-477-3853

Mailing address

1282 Chesterfield Ln
Grayslake, IL 60030-3797

Phone 904-477-3853

Authorized official

Averill Gordon
Owner/ President
9044773853

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