1508803669 NPI number — JORDAN CREEK DIAGNOSTICS

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 1508803669 NPI number — JORDAN CREEK DIAGNOSTICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JORDAN CREEK DIAGNOSTICS
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:
1508803669
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8800 GLACIER HWY
Provider Second Line Business Mailing Address:
SUITE 218
Provider Business Mailing Address City Name:
JUNEAU
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-789-4015
Provider Business Mailing Address Fax Number:
907-789-4016

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8800 GLACIER HWY
Provider Second Line Business Practice Location Address:
SUITE 218
Provider Business Practice Location Address City Name:
JUNEAU
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-789-4015
Provider Business Practice Location Address Fax Number:
907-789-4016
Provider Enumeration Date:
05/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MESDAG
Authorized Official First Name:
FRANK
Authorized Official Middle Name:
F
Authorized Official Title or Position:
LABORATORY DIRECTOR
Authorized Official Telephone Number:
907-789-4015

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2026 www.npivalidator.com