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 1:234 MAY MART DR
Mailing Address - Street 2:
Mailing Address - City:ROCHELLE
Mailing Address - State:IL
Mailing Address - Zip Code:61068-1716
Mailing Address - Country:US
Mailing Address - Phone:815-562-7077
Mailing Address - Fax:815-562-6990
Practice Address - Street 1:234 MAY MART DR
Practice Address - Street 2:
Practice Address - City:ROCHELLE
Practice Address - State:IL
Practice Address - Zip Code:61068-1716
Practice Address - Country:US
Practice Address - Phone:815-562-7077
Practice Address - Fax:815-562-6990
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2009-11-11
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