Healthcare Provider Details

I. General information

NPI: 1922388123
Provider Name (Legal Business Name): TE DEO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2011
Last Update Date: 08/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

627 12TH ST E
GLENCOE MN
55336-2133
US

IV. Provider business mailing address

10374 155TH ST
GLENCOE MN
55336-7502
US

V. Phone/Fax

Practice location:
  • Phone: 320-864-8000
  • Fax: 320-864-8004
Mailing address:
  • Phone: 612-240-0054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number5391
License Number StateMN

VIII. Authorized Official

Name: DR. KURT DONALD KRAMER
Title or Position: OWNER
Credential: STM, DC
Phone: 612-240-0054