Provider Demographics
NPI:1528831997
Name:FLANNIGAN, GORDON
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:
Last Name:FLANNIGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 FLEMING FALLS RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44905-1341
Mailing Address - Country:US
Mailing Address - Phone:419-631-2886
Mailing Address - Fax:
Practice Address - Street 1:1160 FLEMING FALLS RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44905-1341
Practice Address - Country:US
Practice Address - Phone:419-631-2886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRQ953947261QA0600X, 172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care