Provider Demographics
NPI:1801309075
Name:JD RESIDENTIAL CARE, LLC
Entity type:Organization
Organization Name:JD RESIDENTIAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSEE
Authorized Official - Prefix:
Authorized Official - First Name:JOJI
Authorized Official - Middle Name:J
Authorized Official - Last Name:JUNIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-435-9822
Mailing Address - Street 1:2199 MARVEL AVE
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-2211
Mailing Address - Country:US
Mailing Address - Phone:805-791-3461
Mailing Address - Fax:805-842-1107
Practice Address - Street 1:2199 MARVEL AVE
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-2211
Practice Address - Country:US
Practice Address - Phone:805-791-3461
Practice Address - Fax:805-842-1107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-09
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA565802413253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA96035408DMedicaid