Healthcare Provider Details

I. General information

NPI: 1033394861
Provider Name (Legal Business Name): TEDOMER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2007
Last Update Date: 01/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3720 CHURCH ROCK RD
GALLUP NM
87301-4572
US

IV. Provider business mailing address

3720 CHURCH ROCK RD
GALLUP NM
87301-4572
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-2261
  • Fax: 505-722-4732
Mailing address:
  • Phone: 505-722-2261
  • Fax: 505-722-4732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY NMN DOMER
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 505-783-4045