Provider Demographics
NPI:1346890746
Name:JDC PROVIDER, INC
Entity Type:Organization
Organization Name:JDC PROVIDER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:DAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-246-2550
Mailing Address - Street 1:31520 RAILROAD CANYON RD STE A
Mailing Address - Street 2:
Mailing Address - City:CANYON LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:92587-9499
Mailing Address - Country:US
Mailing Address - Phone:951-246-2550
Mailing Address - Fax:951-246-2568
Practice Address - Street 1:31520 RAILROAD CANYON RD STE A
Practice Address - Street 2:
Practice Address - City:CANYON LAKE
Practice Address - State:CA
Practice Address - Zip Code:92587-9499
Practice Address - Country:US
Practice Address - Phone:951-246-2550
Practice Address - Fax:951-246-2568
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JDC PROVIDER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-09-17
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care