Basic Information
| Provider Information | |||||||||
| NPI: | 1699483610 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JORDAN | ||||||||
| FirstName: | REBECCA | ||||||||
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| Credential: | MLS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5770 DOGWOOD CIR | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295887173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4066716536 | ||||||||
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| Practice Location | |||||||||
| Address1: | 809 82ND PKWY | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295724607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436921000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2022 | ||||||||
| LastUpdateDate: | 11/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246QM0706X | N | Technologists, Technicians & Other Technical Service Providers | Spec/Tech, Pathology | Medical Technologist | 390200000X | Y | 193400000X SINGLE SPECIALTY GROUP | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.