Provider Demographics
NPI:1497930945
Name:TJDMEDICAL CENTER
Entity Type:Organization
Organization Name:TJDMEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:720-898-8900
Mailing Address - Street 1:4251 KIPLING ST
Mailing Address - Street 2:SUITE 560
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-2896
Mailing Address - Country:US
Mailing Address - Phone:720-898-8900
Mailing Address - Fax:720-898-8901
Practice Address - Street 1:4251 KIPLING ST
Practice Address - Street 2:SUITE 560
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-2896
Practice Address - Country:US
Practice Address - Phone:720-898-8900
Practice Address - Fax:720-898-8901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO39589261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO83685731Medicaid
COA10548Medicare UPIN
CO83685731Medicaid