Provider Demographics
NPI:1881792596
Name:JEDI VENTURES, LLC
Entity type:Organization
Organization Name:JEDI VENTURES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:LIANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-444-7052
Mailing Address - Street 1:3150 J ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-4403
Mailing Address - Country:US
Mailing Address - Phone:916-444-7052
Mailing Address - Fax:916-446-1145
Practice Address - Street 1:3150 J ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-4403
Practice Address - Country:US
Practice Address - Phone:916-444-7052
Practice Address - Fax:916-446-1145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASUR51062HMedicaid
ZZZ15508ZMedicare PIN