Provider Demographics
NPI:1285289611
Name:GORDON, BRYCE JAY ALLEN (ATC, MA, CES)
Entity type:Individual
Prefix:MR
First Name:BRYCE
Middle Name:JAY ALLEN
Last Name:GORDON
Suffix:
Gender:M
Credentials:ATC, MA, CES
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Mailing Address - Street 1:22 AMATO
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-5144
Mailing Address - Country:US
Mailing Address - Phone:831-332-8838
Mailing Address - Fax:
Practice Address - Street 1:26242 DIMENSION DR STE 150
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-7811
Practice Address - Country:US
Practice Address - Phone:831-332-8838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-02
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer