Healthcare Provider Details

I. General information

NPI: 1689920175
Provider Name (Legal Business Name): JORDAN BRETT GRAFFAGNINO LSA, CSFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2012
Last Update Date: 11/23/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9325 PHELAN BLVD
BEAUMONT TX
77706-5122
US

IV. Provider business mailing address

9325 PHELAN BLVD
BEAUMONT TX
77706-5122
US

V. Phone/Fax

Practice location:
  • Phone: 409-554-1138
  • Fax:
Mailing address:
  • Phone: 409-554-1138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberSA00483
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number136982
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License NumberSA00483
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: