Provider Demographics
NPI:1134164759
Name:JORDAN MEDICAL, LLC
Entity type:Organization
Organization Name:JORDAN MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ROSEMARY
Authorized Official - Middle Name:C
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:606-464-3901
Mailing Address - Street 1:PO BOX 346
Mailing Address - Street 2:
Mailing Address - City:BEATTYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41311-0346
Mailing Address - Country:US
Mailing Address - Phone:606-464-9100
Mailing Address - Fax:606-464-9191
Practice Address - Street 1:1075 HIGHWAY 11 NORTH
Practice Address - Street 2:
Practice Address - City:BEATTYVILLE
Practice Address - State:KY
Practice Address - Zip Code:41311-8719
Practice Address - Country:US
Practice Address - Phone:606-464-9100
Practice Address - Fax:606-464-9191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BC3200X, 332BP3500X, 332BX2000X
KYMG0462332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY90012139Medicaid
KY5236950002Medicare NSC