Provider Demographics
NPI:1144836172
Name:TDETH 1,LLC
Entity type:Organization
Organization Name:TDETH 1,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FRANCHISE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:ETHEREDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-599-4506
Mailing Address - Street 1:7905 GRIFFIN CT
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-1910
Mailing Address - Country:US
Mailing Address - Phone:512-599-4506
Mailing Address - Fax:
Practice Address - Street 1:9722 GREAT HILLS TRL STE 125
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-7265
Practice Address - Country:US
Practice Address - Phone:512-239-8223
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-16
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty