Provider Demographics
NPI:1154399244
Name:TJD, LLC
Entity type:Organization
Organization Name:TJD, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:GORMLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-907-7677
Mailing Address - Street 1:1685 SHAFFER RD
Mailing Address - Street 2:
Mailing Address - City:ATWATER
Mailing Address - State:CA
Mailing Address - Zip Code:95301-4456
Mailing Address - Country:US
Mailing Address - Phone:209-357-3420
Mailing Address - Fax:209-356-2486
Practice Address - Street 1:1685 SHAFFER RD
Practice Address - Street 2:
Practice Address - City:ATWATER
Practice Address - State:CA
Practice Address - Zip Code:95301-4456
Practice Address - Country:US
Practice Address - Phone:209-357-3420
Practice Address - Fax:209-356-2486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA040000070314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC55244HMedicaid
CAZZZM2405ZOtherBLUE SHIELD
CA555244Medicare ID - Type Unspecified