Provider Demographics
NPI:1104533009
Name:IDABEL TEG LLC
Entity type:Organization
Organization Name:IDABEL TEG LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:KAYLA
Authorized Official - Middle Name:E
Authorized Official - Last Name:GRASSIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-329-5051
Mailing Address - Street 1:4109 MOORES LN
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-2159
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2020 S E WASHINGTON
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745
Practice Address - Country:US
Practice Address - Phone:903-329-5051
Practice Address - Fax:903-329-5053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-31
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier