Provider Demographics
NPI:1730728148
Name:GORDON, JANICE
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 W BUTLER RD STE I
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-4809
Mailing Address - Country:US
Mailing Address - Phone:864-269-6985
Mailing Address - Fax:864-751-1619
Practice Address - Street 1:1120 W BUTLER RD STE I
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-4809
Practice Address - Country:US
Practice Address - Phone:864-269-6985
Practice Address - Fax:864-751-1619
Is Sole Proprietor?:No
Enumeration Date:2020-01-02
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2020-34953171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
238290OtherNAICS
532283OtherNAICS
446119OtherNAICS
236118OtherNAICS
238990OtherNAICS
811198OtherNAICS
333921OtherNAICS