Individual
KELLROY GORDON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
530 MALABAR RD SW APT 202, PALM BAY, FL 32907-2992
(321) 614-5082
Mailing address
530 MALABAR RD SW APT 202, PALM BAY, FL 32907-2992
(321) 614-5082
Taxonomy
Speciality
Code
Description
License number
State
372500000X
Chore Provider
—
—
372600000X
Adult Companion
Primary
195341
FL
374700000X
Technician
—
—
3747P1801X
Personal Care Attendant
—
—
376J00000X
Homemaker
—
—
376K00000X
Nurse's Aide
—
—
Other
Enumeration date
02/15/2019
Last updated
02/15/2019
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