Basic Information
| Provider Information | |||||||||
| NPI: | 1396197158 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JORDAN HEALTHCARE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 817 POND VIEW HTS | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146121350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9177165479 | ||||||||
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| Practice Location | |||||||||
| Address1: | 322 LAKE AVE STE 1 | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146081162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852546480 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2016 | ||||||||
| LastUpdateDate: | 07/05/2016 | ||||||||
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| AuthorizedOfficialLastName: | TAUB | ||||||||
| AuthorizedOfficialFirstName: | VLADIMIR | ||||||||
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| AuthorizedOfficialTitleorPosition: | NURSE PRACTITIONER | ||||||||
| AuthorizedOfficialTelephone: | 9177165479 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | FNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.