Basic Information
| Provider Information | |||||||||
| NPI: | 1124166558 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TEC LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TOTAL EYE CARE LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11725 STINSON AVE | ||||||||
| Address2: | |||||||||
| City: | CHISAGO CITY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550139542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512578421 | ||||||||
| FaxNumber: | 6512578464 | ||||||||
| Practice Location | |||||||||
| Address1: | 5200 FAIRVIEW BLVD | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550928013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512578421 | ||||||||
| FaxNumber: | 6512578464 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 11/25/2013 | ||||||||
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| AuthorizedOfficialLastName: | SWANNER | ||||||||
| AuthorizedOfficialFirstName: | GENNY | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6512578421 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 827983700 | 05 | MN | MEDICAID |