MEDICARE: MS. JORDAN ARDREY MYERS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer		NV

General Provider Information

NPI Number	:	1033682240
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JORDAN ARDREY MYERS

Provider Business Mailing Address
First Line	:	PO BOX 1146
Second Line	:
City	:	CARNELIAN BAY
State	:	CA
Zip	:	96140-1146
Country	:	US
Telephone Number	:	803-308-3857
Fax Number	:

Provider Business Practice Location Address
First Line	:	5385 N LAKE BLVD
Second Line	:
City	:	CARNELIAN BAY
State	:	CA
Zip	:	96140-1146
Country	:	US
Telephone Number	:	803-308-3857
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/10/2019
Last Update Date	:	01/10/2019

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