=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295150597
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROBERT JORDAN HEALTH SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2014
-----------------------------------------------------
Last Update Date | 02/23/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6810 TILDEN LN
-----------------------------------------------------
City | ROCKVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20852-4501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-468-3962
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6810 TILDEN LN
-----------------------------------------------------
City | ROCKVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20852-4501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-468-3962
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. ROBERT J JORDAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 301-468-3962
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | M02335
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------