1114936036 NPI number — MRS. LORELL CYNTHIA GORDON LICENSED PROFESSIONA

Table of content: MRS. LORELL CYNTHIA GORDON LICENSED PROFESSIONA (NPI 1114936036)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114936036 NPI number — MRS. LORELL CYNTHIA GORDON LICENSED PROFESSIONA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORDON
Provider First Name:
LORELL
Provider Middle Name:
CYNTHIA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LICENSED PROFESSIONA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114936036
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8 MONTFORD AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOILING SPRINGS
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29816
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-578-5069
Provider Business Mailing Address Fax Number:
864-578-5068

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
167 ALABAMA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPARTANBURG
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-583-1010
Provider Business Practice Location Address Fax Number:
864-582-6361
Provider Enumeration Date:
08/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  3423 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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