Provider Demographics
NPI:1457374811
Name:JORDAN-GARDNER, KELI ELIZABETH (OD)
Entity type:Individual
Prefix:MRS
First Name:KELI
Middle Name:ELIZABETH
Last Name:JORDAN-GARDNER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3055 WABASH AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-6414
Mailing Address - Country:US
Mailing Address - Phone:217-793-2273
Mailing Address - Fax:
Practice Address - Street 1:8309 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-2170
Practice Address - Country:US
Practice Address - Phone:309-693-9540
Practice Address - Fax:309-693-9542
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL468857152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
7106766OtherBCBS
IL1073060001Medicare NSC
IL379510Medicare PIN
7106766OtherBCBS