Provider Demographics
NPI:1376115477
Name:JORDAN, ROLLIE III
Entity Type:Individual
Prefix:
First Name:ROLLIE
Middle Name:
Last Name:JORDAN
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3125 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-2703
Mailing Address - Country:US
Mailing Address - Phone:213-482-6400
Mailing Address - Fax:
Practice Address - Street 1:3125 N BROADWAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90031-2703
Practice Address - Country:US
Practice Address - Phone:213-482-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist