1124757745 NPI number — JORDAN RESIDENTIAL & VOCATIONAL SERVICES INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124757745 NPI number — JORDAN RESIDENTIAL & VOCATIONAL SERVICES INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JORDAN RESIDENTIAL & VOCATIONAL SERVICES INC.
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:
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:
1124757745
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/08/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8477
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUEBLO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81008-8477
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-251-4604
Provider Business Mailing Address Fax Number:
719-545-8583

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2928 WITHERS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUEBLO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81008-1248
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-543-8178
Provider Business Practice Location Address Fax Number:
719-545-8583
Provider Enumeration Date:
06/08/2022

Additional Information

Authorized Official

Authorized Official Last Name:
JORDAN
Authorized Official First Name:
MIKE
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
719-251-4604

Provider Taxonomy Codes

  • Taxonomy code: 320900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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