Provider Demographics
NPI:1114099462
Name:JORDAN CHIROPRACTIC CLINIC S.C.
Entity Type:Organization
Organization Name:JORDAN CHIROPRACTIC CLINIC S.C.
Other - Org Name:JORDAN CHIROPRACTIC CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-284-5551
Mailing Address - Street 1:438 N WATER ST
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615-1005
Mailing Address - Country:US
Mailing Address - Phone:715-284-5551
Mailing Address - Fax:715-284-9164
Practice Address - Street 1:438 N WATER ST
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615-1005
Practice Address - Country:US
Practice Address - Phone:715-284-5551
Practice Address - Fax:715-284-9164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38992500Medicaid
WI38992500Medicaid