Basic Information
Provider Information | |||||||||
NPI: | 1972937506 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TEC LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | TOTAL EYE CARE LLC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 11725 STINSON AVE | ||||||||
Address2: |   | ||||||||
City: | CHISAGO CITY | ||||||||
State: | MN | ||||||||
PostalCode: | 550139542 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6512578421 | ||||||||
FaxNumber: | 6512578464 | ||||||||
Practice Location | |||||||||
Address1: | 5366 386TH ST NE | ||||||||
Address2: |   | ||||||||
City: | NORTH BRANCH | ||||||||
State: | MN | ||||||||
PostalCode: | 550565833 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6516746844 | ||||||||
FaxNumber: | 6516746845 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/30/2013 | ||||||||
LastUpdateDate: | 01/14/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SWANNER | ||||||||
AuthorizedOfficialFirstName: | GENNY | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 6512578421 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | 0193 | MN | Y |   | Suppliers | Eyewear Supplier (Equipment, not the service) |   |
ID Information
ID | Type | State | Issuer | Description | 827983700 | 05 | MN |   | MEDICAID |