MEDICARE: MRS. KIM H JORDAN

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	343900000X	Non-emergency Medical Transport (VAN)

General Provider Information

NPI Number	:	1376921536
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIM H JORDAN

Provider Business Mailing Address
First Line	:	1305 CANTERBURY LN
Second Line	:
City	:	COLONIAL HEIGHTS
State	:	VA
Zip	:	23834-2711
Country	:	US
Telephone Number	:	804-855-9503
Fax Number	:

Provider Business Practice Location Address
First Line	:	1305 CANTERBURY LN
Second Line	:
City	:	COLONIAL HEIGHTS
State	:	VA
Zip	:	23834-2711
Country	:	US
Telephone Number	:	804-855-9503
Fax Number	:

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

Provider Enumeration Date	:	05/08/2015
Last Update Date	:	05/08/2015

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