=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154067759
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR JIJI'S INTEGRAL HEALTH CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2022
-----------------------------------------------------
Last Update Date | 05/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 W PARK ROW DR STE A
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76010-2559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-414-6033
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 174497
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76003-4497
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-414-6033
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER AND FOUNDER
-----------------------------------------------------
Name | DR. PAMELA J RANDOLPH
-----------------------------------------------------
Credential | LCDC
-----------------------------------------------------
Telephone | 214-414-6033
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------