MEDICARE: JORDAN GARDO

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1164241436
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN GARDO

Provider Business Mailing Address
First Line	:	123 SANDY ACRES DR
Second Line	:
City	:	BRUCETON MILLS
State	:	WV
Zip	:	26525-5701
Country	:	US
Telephone Number	:	304-698-9776
Fax Number	:

Provider Business Practice Location Address
First Line	:	123 SANDY ACRES DR
Second Line	:
City	:	BRUCETON MILLS
State	:	WV
Zip	:	26525-5701
Country	:	US
Telephone Number	:	304-698-9776
Fax Number	:

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

Provider Enumeration Date	:	10/04/2024
Last Update Date	:	10/04/2024

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Directions to “ JORDAN GARDO ” Practice Location

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