1073901013 NPI number — ASHLEY JORDAN

Table of content: (NPI 1073901013)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073901013 NPI number — ASHLEY JORDAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ASHLEY JORDAN
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1073901013
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 871
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUBURN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36831-0871
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-329-6063
Provider Business Mailing Address Fax Number:
972-499-1005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
118 N ROSS ST
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
AUBURN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36830-4869
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-332-5214
Provider Business Practice Location Address Fax Number:
334-329-6063
Provider Enumeration Date:
12/29/2014

Additional Information

Authorized Official

Authorized Official Last Name:
JORDAN
Authorized Official First Name:
ASHLEY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
334-329-6063

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  3680C , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 102I808963 . This is a "PTAN" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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