MEDICARE: DWAYNE 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	251E00000X	Home Health Agency	258361	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487062204
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DWAYNE JORDAN

Provider Business Mailing Address
First Line	:	6611 WILKINS AVENUE
Second Line	:
City	:	PITTSBURGH
State	:	PA
Zip	:	15217
Country	:	US
Telephone Number	:	412-294-2555
Fax Number	:

Provider Business Practice Location Address
First Line	:	6611 WILKINS AVE
Second Line	:
City	:	PITTSBURGH
State	:	PA
Zip	:	15217-1316
Country	:	US
Telephone Number	:	412-294-2555
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DWAYNE JORDAN
Credential	:
Telephone Number	:	412-294-2555

Provider Enumeration Date	:	07/24/2014
Last Update Date	:	08/22/2014

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