Provider Demographics
NPI:1265287205
Name:LJ EDWARDS LLC
Entity type:Organization
Organization Name:LJ EDWARDS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LICIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON-EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:757-663-3633
Mailing Address - Street 1:2109 DES MOINES AVE
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-5421
Mailing Address - Country:US
Mailing Address - Phone:757-663-3633
Mailing Address - Fax:
Practice Address - Street 1:5215 COLLEY AVE STE 109
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23508-2166
Practice Address - Country:US
Practice Address - Phone:757-994-1194
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-23
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty