Provider Demographics
NPI:1154047389
Name:TJ FOUR FAMILY
Entity type:Organization
Organization Name:TJ FOUR FAMILY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:S
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:308-440-2983
Mailing Address - Street 1:245 SUNNY LN
Mailing Address - Street 2:
Mailing Address - City:GIBBON
Mailing Address - State:NE
Mailing Address - Zip Code:68840-6282
Mailing Address - Country:US
Mailing Address - Phone:308-440-2983
Mailing Address - Fax:
Practice Address - Street 1:5205 2ND AVE
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68847-2471
Practice Address - Country:US
Practice Address - Phone:308-440-2983
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-19
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care