Basic Information
| Provider Information | |||||||||
| NPI: | 1841872728 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JORDAN RIDGE FAMILY MEDICINE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 35380 | ||||||||
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| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891335380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025793253 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1403 EAST SEGO LANE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SANDY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3852743959 | ||||||||
| FaxNumber: | 3852743970 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2021 | ||||||||
| LastUpdateDate: | 10/28/2022 | ||||||||
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| AuthorizedOfficialLastName: | CASTILLO | ||||||||
| AuthorizedOfficialFirstName: | EMILY | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7024802550 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0207X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mobile Mammography |
No ID Information.