Healthcare Provider Details

I. General information

NPI: 1366726861
Provider Name (Legal Business Name): PHILIP RUSSELL JORDAN D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2011
Last Update Date: 05/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2741 WHISKEY RD
AIKEN SC
29803-6197
US

IV. Provider business mailing address

2741 WHISKEY RD
AIKEN SC
29803-6197
US

V. Phone/Fax

Practice location:
  • Phone: 803-226-0217
  • Fax: 803-226-0459
Mailing address:
  • Phone: 803-226-0217
  • Fax: 803-226-0459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3663
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: