=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669120796
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JORDAN SPINE & REHAB CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2022
-----------------------------------------------------
Last Update Date | 03/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 YOUNT DR STE 4
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61704-3737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-431-2357
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 307 BEACON CIR
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61704-1442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-531-9374
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | DR. LAUREN MICHELLE JORDAN
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 309-431-2357
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------