Healthcare Provider Details

I. General information

NPI: 1982138996
Provider Name (Legal Business Name): IJT9112 AND ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2017
Last Update Date: 12/28/2023
Certification Date: 12/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9112 WAKARUSA ST
LA MESA CA
91942-3308
US

IV. Provider business mailing address

9112 WAKARUSA ST
LA MESA CA
91942-3308
US

V. Phone/Fax

Practice location:
  • Phone: 619-741-2499
  • Fax:
Mailing address:
  • Phone: 619-741-2499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number374603906
License Number StateCA

VIII. Authorized Official

Name: RICHARD ANTHONY EDWARDS
Title or Position: HEALTHCARE ADMINISTRATOR
Credential:
Phone: 619-954-0963