Healthcare Provider Details

I. General information

NPI: 1508995762
Provider Name (Legal Business Name): TDK FAMILY MEDICAL CENTERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 05/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2434 WOLF RD
WESTCHESTER IL
60154-5634
US

IV. Provider business mailing address

2434 WOLF RD
WESTCHESTER IL
60154-5634
US

V. Phone/Fax

Practice location:
  • Phone: 708-562-5430
  • Fax: 708-562-8330
Mailing address:
  • Phone: 708-562-5430
  • Fax: 708-562-8330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. THOMAS M NELSON
Title or Position: MANAGING PARTNER
Credential: D.O.
Phone: 708-562-5430