Basic Information
| Provider Information | |||||||||
| NPI: | 1124462734 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | JEREMIAH | ||||||||
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| Credential: | LPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 S GAREY AVE SPC 61 | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917665260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9092727989 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3881 S WESTERN AVE | ||||||||
| Address2: | 2500 WILSHIRE BLVD SUITE 500 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900621105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2136390251 | ||||||||
| FaxNumber: | 2133897358 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2013 | ||||||||
| LastUpdateDate: | 04/25/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 167G00000X | 36785 | CA | Y | Nursing Service Providers | Licensed Psychiatric Technician |
No ID Information.