Provider Demographics
NPI:1518357995
Name:THE BEN GORDON CENTER
Entity type:Organization
Organization Name:THE BEN GORDON CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:BETTYBO
Authorized Official - Middle Name:
Authorized Official - Last Name:BIEBERITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-756-4875
Mailing Address - Street 1:12 HEALTH SERVICES DR
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-9637
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12 HEALTH SERVICES DR
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-9637
Practice Address - Country:US
Practice Address - Phone:815-756-4875
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-23
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health