Provider Demographics
NPI:1760290894
Name:VAN GORDER, JEFFREY ANDREW
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ANDREW
Last Name:VAN GORDER
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 1:6425 CANTERWOOD RD
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-1211
Mailing Address - Country:US
Mailing Address - Phone:909-267-4342
Mailing Address - Fax:
Practice Address - Street 1:6425 CANTERWOOD RD
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-1211
Practice Address - Country:US
Practice Address - Phone:909-267-4342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-20
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes177F00000XOther Service ProvidersLodging