Provider Demographics
NPI:1972793347
Name:JORDAN, DIANE MARIE (DC)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:MARIE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1848 S ELENA AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-5710
Mailing Address - Country:US
Mailing Address - Phone:310-375-4039
Mailing Address - Fax:310-375-5184
Practice Address - Street 1:1848 S ELENA AVE
Practice Address - Street 2:SUITE D
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-5710
Practice Address - Country:US
Practice Address - Phone:310-375-4039
Practice Address - Fax:310-375-5184
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-31
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC14413111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CATO5364Medicare UPIN