Individual
MIKE JORDAN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
2928 WITHERS AVE, PUEBLO, CO 81008-1248
(719) 543-8178
(719) 545-8583
Mailing address
PO BOX 8477, PUEBLO, CO 81008-8477
(719) 543-8178
(719) 545-8583
Taxonomy
Speciality
Code
Description
License number
State
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
47835346
—
CO
Enumeration date
09/03/2015
Last updated
09/03/2015
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