1639362809 NPI number — MR. AVERY MILES JORDAN LPTA/LPN

Table of content: MR. AVERY MILES JORDAN LPTA/LPN (NPI 1639362809)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639362809 NPI number — MR. AVERY MILES JORDAN LPTA/LPN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JORDAN
Provider First Name:
AVERY
Provider Middle Name:
MILES
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LPTA/LPN
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639362809
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/21/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3708 STAMFORD CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDLOTHIAN
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23112-3671
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-744-5303
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 E BROAD ROCK RD
Provider Second Line Business Practice Location Address:
RM 1S-112
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23249-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-675-5000
Provider Business Practice Location Address Fax Number:
804-675-5335
Provider Enumeration Date:
08/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 164W00000X , with the licence number:  0002040749 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225200000X , with the licence number: 2306001152 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com