Provider Demographics
NPI:1184302408
Name:JORDAN, RENWICK LEE SR
Entity type:Individual
Prefix:MR
First Name:RENWICK
Middle Name:LEE
Last Name:JORDAN
Suffix:SR
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 1:6980 SAINT FRANCIS AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70811-1419
Mailing Address - Country:US
Mailing Address - Phone:225-235-8879
Mailing Address - Fax:
Practice Address - Street 1:6980 SAINT FRANCIS AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70811-1419
Practice Address - Country:US
Practice Address - Phone:225-235-8879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)