Healthcare Provider Details

I. General information

NPI: 1841784170
Provider Name (Legal Business Name): JORDAN DREW BETTLEYON MS, LAT, ATC, EP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 08/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 RAMSEY ST
FAYETTEVILLE NC
28311
US

IV. Provider business mailing address

408 TARTAN CT
FAYETTEVILLE NC
28311-1694
US

V. Phone/Fax

Practice location:
  • Phone: 910-630-7000
  • Fax:
Mailing address:
  • Phone: 570-274-6387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberRTO000311
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number003597
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number3994
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: