1386172864 NPI number — DR. JORDAN ELIZABETH DIETERLE DC

Table of content: DR. JORDAN ELIZABETH DIETERLE DC (NPI 1386172864)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386172864 NPI number — DR. JORDAN ELIZABETH DIETERLE DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIETERLE
Provider First Name:
JORDAN
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DC
Provider Gender Code:
F

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:
1386172864
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3443 TAMIAMI TRL STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT CHARLOTTE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33952-8159
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-625-2667
Provider Business Mailing Address Fax Number:
941-315-9922

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3704 WEBBER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SARASOTA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34232-4416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-554-6506
Provider Business Practice Location Address Fax Number:
941-315-9922
Provider Enumeration Date:
05/30/2017

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: 111N00000X , with the licence number:  CH12104 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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