=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225117419
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JORDAN & GILLIS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2006
-----------------------------------------------------
Last Update Date | 02/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1026 E GOODE ST
-----------------------------------------------------
City | QUITMAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75783-1641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-763-2284
-----------------------------------------------------
Fax | 903-763-4301
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1026 E GOODE ST
-----------------------------------------------------
City | QUITMAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75783-1641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-763-2284
-----------------------------------------------------
Fax | 903-763-4301
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | RHONDA ROLEN
-----------------------------------------------------
Credential | LNFA
-----------------------------------------------------
Telephone | 903-763-2284
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 000410803
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------