=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891335238
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TEDLA CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2020
-----------------------------------------------------
Last Update Date | 02/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3451 KILBURN CIR APT 722
-----------------------------------------------------
City | HENRICO
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23233-1140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-728-0559
-----------------------------------------------------
Fax | 804-800-4117
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 322
-----------------------------------------------------
City | SOUTH PLAINFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07080-0322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-930-2476
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | SAMMY TEDLA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 301-326-6848
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------