1285288324 NPI number — MR. JOSEPH LEE ROY GORDON JR. DSHS, CCHI

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285288324 NPI number — MR. JOSEPH LEE ROY GORDON JR. DSHS, CCHI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORDON
Provider First Name:
JOSEPH
Provider Middle Name:
LEE ROY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
DSHS, CCHI
Provider Gender Code:
M

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:
1285288324
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/26/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4301 NE 4TH ST UNIT 2738
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RENTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98059-9997
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-200-9916
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5132 NE 8TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RENTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98059-4099
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-200-9916
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/26/2019

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: 171R00000X , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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