Provider Demographics
NPI:1033394861
Name:TEDOMER LLC
Entity Type:Organization
Organization Name:TEDOMER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:NMN
Authorized Official - Last Name:DOMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-783-4045
Mailing Address - Street 1:3720 CHURCH ROCK RD
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-4572
Mailing Address - Country:US
Mailing Address - Phone:505-722-2261
Mailing Address - Fax:505-722-4732
Practice Address - Street 1:3720 CHURCH ROCK RD
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-4572
Practice Address - Country:US
Practice Address - Phone:505-722-2261
Practice Address - Fax:505-722-4732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty