Basic Information
| Provider Information | |||||||||
| NPI: | 1700465143 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAIR | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | CHANDLER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4933 NARRAGANSETT DR | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234625850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573331985 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 293 INDEPENDENCE BLVD STE 400 | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234625461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574903009 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2021 | ||||||||
| LastUpdateDate: | 04/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-21-161686 | VA | Y |
No ID Information.