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NPI Code Detail

MEDICARE: MRS. KELI ELIZABETH JORDAN-GARDNER OD

MEDICARE: MRS. KELI ELIZABETH JORDAN-GARDNER OD
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
1152W00000XOptometrist468857IL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
17106766OTHERBCBS

General Provider Information

NPI Number : 1457374811
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. KELI ELIZABETH JORDAN-GARDNER OD
Provider Business Mailing Address
First Line : 3055 WABASH AVE
Second Line :
City : SPRINGFIELD
State : IL
Zip : 62704-6414
Country : US
Telephone Number : 217-793-2273
Fax Number :
Provider Business Practice Location Address
First Line : 8309 N KNOXVILLE AVE
Second Line :
City : PEORIA
State : IL
Zip : 61615-2170
Country : US
Telephone Number : 309-693-9540
Fax Number : 309-693-9542
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/26/2006
Last Update Date : 06/02/2026

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