MEDICARE: TEDLAVIP CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	343900000X	Non-emergency Medical Transport (VAN)

General Provider Information

NPI Number	:	1629814199
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TEDLAVIP CORPORATION

Provider Business Mailing Address
First Line	:	1424 ARAPAHOE RIDGE DR
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27604-9711
Country	:	US
Telephone Number	:	984-800-7318
Fax Number	:

Provider Business Practice Location Address
First Line	:	1424 ARAPAHOE RIDGE DR
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27604-9711
Country	:	US
Telephone Number	:	984-800-7318
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. SAMMY KAHSAY TEDLA
Credential	:
Telephone Number	:	301-326-6848

Provider Enumeration Date	:	07/03/2024
Last Update Date	:	07/03/2024

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