Provider Demographics
NPI:1982138996
Name:IJT9112 AND ASSOCIATES LLC
Entity Type:Organization
Organization Name:IJT9112 AND ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTHCARE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-954-0963
Mailing Address - Street 1:9112 WAKARUSA ST
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3308
Mailing Address - Country:US
Mailing Address - Phone:619-741-2499
Mailing Address - Fax:
Practice Address - Street 1:9112 WAKARUSA ST
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3308
Practice Address - Country:US
Practice Address - Phone:619-741-2499
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-17
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA374603906310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility