Basic Information
| Provider Information | |||||||||
| NPI: | 1679756001 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JORDAN NICHOLS | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 135 N NORTHWEST HWY | ||||||||
| Address2: | |||||||||
| City: | PARK RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478235077 | ||||||||
| FaxNumber: | 8478230371 | ||||||||
| Practice Location | |||||||||
| Address1: | 135 N NORTHWEST HWY | ||||||||
| Address2: | |||||||||
| City: | PARK RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478235077 | ||||||||
| FaxNumber: | 8478230371 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2007 | ||||||||
| LastUpdateDate: | 03/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | NICHOLS | ||||||||
| AuthorizedOfficialFirstName: | JORDAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8478235077 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0131X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery |
No ID Information.