MEDICARE: MR. ANTHONY JORDAN SR. PERSONAL CHEF

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174200000X	Meals Provider	RC420468	OH
2	174200000X	Meals Provider
3	332U00000X	Home Delivered Meals		OH
4	174200000X	Meals Provider		OH

General Provider Information

NPI Number	:	1457940819
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ANTHONY JORDAN SR. PERSONAL CHEF

Provider Business Mailing Address
First Line	:	4657 KIRBY AVE APT 2
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45223-1521
Country	:	US
Telephone Number	:	513-746-8233
Fax Number	:

Provider Business Practice Location Address
First Line	:	4657 KIRBY AVE APT 2
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45223-1521
Country	:	US
Telephone Number	:	513-746-8233
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2021
Last Update Date	:	01/11/2021

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