Provider Demographics
NPI:1184484222
Name:TEDDER OPTOMETRY GROUP, PC
Entity type:Organization
Organization Name:TEDDER OPTOMETRY GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:TEDDER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:805-624-1255
Mailing Address - Street 1:530 NEW LOS ANGELES AVE STE 115-269
Mailing Address - Street 2:
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-2081
Mailing Address - Country:US
Mailing Address - Phone:805-624-1255
Mailing Address - Fax:
Practice Address - Street 1:939 W ARROW HWY
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-2410
Practice Address - Country:US
Practice Address - Phone:805-624-1255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-19
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty