Provider Demographics
NPI:1780072314
Name:IJOMAH, HARDY
Entity type:Individual
Prefix:
First Name:HARDY
Middle Name:
Last Name:IJOMAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1041 STONE HAVEN COURT
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507
Mailing Address - Country:US
Mailing Address - Phone:619-857-0938
Mailing Address - Fax:
Practice Address - Street 1:480 JAMACHA RD APT 2
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92019-2440
Practice Address - Country:US
Practice Address - Phone:619-857-0938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-06
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT10626225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant