Provider Demographics
NPI:1871217042
Name:IWILL TIL IMWELL LLC
Entity type:Organization
Organization Name:IWILL TIL IMWELL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JILLANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROVARIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:504-874-5809
Mailing Address - Street 1:1252 CLAYBURN LN
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95121-2610
Mailing Address - Country:US
Mailing Address - Phone:504-874-5809
Mailing Address - Fax:
Practice Address - Street 1:1252 CLAYBURN LN
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95121-2610
Practice Address - Country:US
Practice Address - Phone:504-874-5809
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-30
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)