Provider Demographics
NPI:1720442080
Name:TCDME
Entity Type:Organization
Organization Name:TCDME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:LATHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-800-8375
Mailing Address - Street 1:PO BOX 1734
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84059-1734
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:815 W 200 S
Practice Address - Street 2:PO BOX 74
Practice Address - City:PAROWAN
Practice Address - State:UT
Practice Address - Zip Code:84761-0074
Practice Address - Country:US
Practice Address - Phone:801-800-8375
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-12
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY2016000711468332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY2016000711468OtherED MURRAY, WY SECRETARY OF STATE
7589290001OtherPTAN