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General NPI Number Information
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NPI Number | 1053308577
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Entity Type | Organization
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Legal Business Name | EDJ LLC
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Dates
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Enumeration Date | 09/30/2005
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Last Update Date | 09/21/2020
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Provider Practice Location Address
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Address Line | 461 S CANFIELD NILES RD
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City | YOUNGSTOWN
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State | OH
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Zip | 44515-4022
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Country | US
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Telephone | 330-270-3468
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Fax |
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Provider Business Mailing Address
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Address Line | 461 S CANFIELD NILES RD
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City | YOUNGSTOWN
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State | OH
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Zip | 44515-4022
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Country | US
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Telephone | 330-270-3468
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Fax |
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Authorized Official
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Title or Position | MEMBER/ADMINASTRATOR
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Name | MRS. DIANE J REESE
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Credential |
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Telephone | 330-270-3468
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 0607R
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 0607N
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License Number State | OH
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