MEDICARE: RIVER JORDAN, INC.

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	253J00000X	Foster Care Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	S351040139364	OTHER	MI	DRIVERS LICENSE

General Provider Information

NPI Number	:	1497414759
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVER JORDAN, INC.

Provider Business Mailing Address
First Line	:	3442 KIESEL RD
Second Line	:
City	:	BAY CITY
State	:	MI
Zip	:	48706-2446
Country	:	US
Telephone Number	:	989-671-7431
Fax Number	:

Provider Business Practice Location Address
First Line	:	3442 KIESEL RD
Second Line	:
City	:	BAY CITY
State	:	MI
Zip	:	48706-2446
Country	:	US
Telephone Number	:	989-671-7431
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	ALAND STAMPS
Credential	:
Telephone Number	:	989-671-7431

Provider Enumeration Date	:	12/14/2021
Last Update Date	:	12/14/2021

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