Provider Demographics
NPI:1053724203
Name:RENEE GORDON LLC
Entity type:Organization
Organization Name:RENEE GORDON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:CANDACE
Authorized Official - Last Name:AHLMARK-GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:229-344-6117
Mailing Address - Street 1:2405 ASHFORD DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31721-9246
Mailing Address - Country:US
Mailing Address - Phone:229-344-6117
Mailing Address - Fax:
Practice Address - Street 1:2405 ASHFORD DR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31721-9246
Practice Address - Country:US
Practice Address - Phone:229-344-6117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002136152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty