1154399244 NPI number — TJD, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154399244 NPI number — TJD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TJD, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ANBERRY REHABILITATION HOSPITAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154399244
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/13/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1685 SHAFFER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATWATER
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95301-4456
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-357-3420
Provider Business Mailing Address Fax Number:
209-356-2486

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1685 SHAFFER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATWATER
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95301-4456
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-357-3420
Provider Business Practice Location Address Fax Number:
209-356-2486
Provider Enumeration Date:
03/14/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GORMLY
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
WALTER
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
714-907-7677

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  040000070 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: LTC55244H , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZM2405Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".