Provider Demographics
NPI:1942473392
Name:WEINER, JORDAN (LMT)
Entity Type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:
Last Name:WEINER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15762 GLEN WILLOW LN
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-6358
Mailing Address - Country:US
Mailing Address - Phone:561-784-0021
Mailing Address - Fax:561-784-0021
Practice Address - Street 1:15762 GLEN WILLOW LN
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-6358
Practice Address - Country:US
Practice Address - Phone:561-784-0021
Practice Address - Fax:561-784-0021
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-07
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA38880172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist