=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801291802
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TEG INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2014
-----------------------------------------------------
Last Update Date | 11/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4143 LEGENDARY DR
-----------------------------------------------------
City | DESTIN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32541-5393
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-650-4370
-----------------------------------------------------
Fax | 850-650-0193
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 520 8TH AVE 23RD FLOOR
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10018-6507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-792-8149
-----------------------------------------------------
Fax | 646-448-3327
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING MANAGER
-----------------------------------------------------
Name | LAURA VALENTIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 212-792-8149
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------