Provider Demographics
NPI:1083399828
Name:TENGLIN, JACK RYAN
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:RYAN
Last Name:TENGLIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13973 FARMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-5403
Mailing Address - Country:US
Mailing Address - Phone:734-855-4490
Mailing Address - Fax:
Practice Address - Street 1:13973 FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-5403
Practice Address - Country:US
Practice Address - Phone:734-855-4490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist