Healthcare Provider Details

I. General information

NPI: 1154399244
Provider Name (Legal Business Name): TJD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 11/13/2020
Certification Date: 11/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1685 SHAFFER RD
ATWATER CA
95301-4456
US

IV. Provider business mailing address

1685 SHAFFER RD
ATWATER CA
95301-4456
US

V. Phone/Fax

Practice location:
  • Phone: 209-357-3420
  • Fax: 209-356-2486
Mailing address:
  • Phone: 209-357-3420
  • Fax: 209-356-2486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number040000070
License Number StateCA

VIII. Authorized Official

Name: DONALD WALTER GORMLY
Title or Position: MEMBER
Credential:
Phone: 714-907-7677