MEDICARE: DR. DIANE MARIE JORDAN DC

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	111N00000X	Chiropractor	DC14413	CA

General Provider Information

NPI Number	:	1972793347
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIANE MARIE JORDAN DC

Provider Business Mailing Address
First Line	:	1848 S ELENA AVE
Second Line	:	SUITE D
City	:	REDONDO BEACH
State	:	CA
Zip	:	90277-5710
Country	:	US
Telephone Number	:	310-375-4039
Fax Number	:	310-375-5184

Provider Business Practice Location Address
First Line	:	1848 S ELENA AVE
Second Line	:	SUITE D
City	:	REDONDO BEACH
State	:	CA
Zip	:	90277-5710
Country	:	US
Telephone Number	:	310-375-4039
Fax Number	:	310-375-5184

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

Provider Enumeration Date	:	07/31/2007
Last Update Date	:	07/31/2007

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