Healthcare Provider Details

I. General information

NPI: 1073128294
Provider Name (Legal Business Name): JORDAN ELIZABETH RICE CERTIFIED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2020
Last Update Date: 09/14/2020
Certification Date: 09/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 ROBLE GRANDE RD
ALPINE CA
91901-3024
US

IV. Provider business mailing address

1717 ROBLE GRANDE RD
ALPINE CA
91901-3024
US

V. Phone/Fax

Practice location:
  • Phone: 619-917-6249
  • Fax:
Mailing address:
  • Phone: 619-917-6249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number72403
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: