Provider Demographics
NPI:1669120796
Name:JORDAN SPINE & REHAB CENTER LLC
Entity type:Organization
Organization Name:JORDAN SPINE & REHAB CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-431-2357
Mailing Address - Street 1:307 BEACON CIR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-1442
Mailing Address - Country:US
Mailing Address - Phone:309-531-9374
Mailing Address - Fax:
Practice Address - Street 1:4 YOUNT DR STE 4
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3737
Practice Address - Country:US
Practice Address - Phone:309-431-2357
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-17
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center