Provider Demographics
NPI:1528657905
Name:GORDON, LETEISHA MECHI'ELL
Entity type:Individual
Prefix:
First Name:LETEISHA
Middle Name:MECHI'ELL
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:PO BOX 7629
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23231-0129
Mailing Address - Country:US
Mailing Address - Phone:804-299-1932
Mailing Address - Fax:
Practice Address - Street 1:1600 PRESSON BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23224-8020
Practice Address - Country:US
Practice Address - Phone:804-299-1932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT63629900171WV0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WV0202XOther Service ProvidersContractorVehicle Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAT63629900OtherDMV LICENSE