Basic Information
| Provider Information | |||||||||
| NPI: | 1275192742 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURCH | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | GRAF | ||||||||
| OtherFirstName: | JORDAN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1222 S PATTERSON BLVD | ||||||||
| Address2: | STE 400 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454022642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374962620 | ||||||||
| FaxNumber: | 9374248518 | ||||||||
| Practice Location | |||||||||
| Address1: | 6601 CENTERVILLE BUSINESS PKWY | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454592691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374357476 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2019 | ||||||||
| LastUpdateDate: | 07/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | Y | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
No ID Information.