Provider Demographics
NPI:1285340547
Name:TJ GARDNER CENTER LLC
Entity type:Organization
Organization Name:TJ GARDNER CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HAYDEN
Authorized Official - Middle Name:WON MIN PHILLIP
Authorized Official - Last Name:DUFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-466-4837
Mailing Address - Street 1:1722 N BANNING STE 101B
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-3350
Mailing Address - Country:US
Mailing Address - Phone:480-466-4837
Mailing Address - Fax:
Practice Address - Street 1:1722 N BANNING STE 101B
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-3350
Practice Address - Country:US
Practice Address - Phone:480-466-4837
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-30
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty