Healthcare Provider Details

I. General information

NPI: 1326695495
Provider Name (Legal Business Name): JORDAN WAN M.T., TAI NA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2019
Last Update Date: 08/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1141 SMITH LANE STE #3 STE #3
ROSEVILLE OH
95661-4123
US

IV. Provider business mailing address

1141 SMITH LANE STE #3 STE #3
ROSEVILLE OH
95661-4123
US

V. Phone/Fax

Practice location:
  • Phone: 916-783-3003
  • Fax: 916-783-4799
Mailing address:
  • Phone: 916-783-3003
  • Fax: 916-783-4799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number71847798
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: