Provider Demographics
NPI:1063038719
Name:TEA PAIN
Entity Type:Organization
Organization Name:TEA PAIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:RATIBU
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMANGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-488-6907
Mailing Address - Street 1:7612 SUN VISTA WAY
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-7501
Mailing Address - Country:US
Mailing Address - Phone:404-488-6907
Mailing Address - Fax:
Practice Address - Street 1:6220 S ORANGE BLOSSOM TRL
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-4630
Practice Address - Country:US
Practice Address - Phone:404-488-6907
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-18
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies