Provider Demographics
NPI:1154304780
Name:JORDE, ERIC LAWRENCE (PT)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:LAWRENCE
Last Name:JORDE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2820 WATERFORD LAKE DR
Mailing Address - Street 2:STE 103
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-3994
Mailing Address - Country:US
Mailing Address - Phone:804-249-8277
Mailing Address - Fax:804-249-9690
Practice Address - Street 1:2820 WATERFORD LAKE DR
Practice Address - Street 2:STE 103
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-3994
Practice Address - Country:US
Practice Address - Phone:804-249-8277
Practice Address - Fax:804-249-9690
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305202925225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
006452T79Medicare PIN
VA006452T79Medicare ID - Type Unspecified