Provider Demographics
NPI:1356488506
Name:TEDESCO OPTICAL, INC.
Entity Type:Organization
Organization Name:TEDESCO OPTICAL, INC.
Other - Org Name:RAPHAEL OPTICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAFFAELE
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:TEDESCO
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:914-949-0575
Mailing Address - Street 1:337 MAMARONECK AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10605-1440
Mailing Address - Country:US
Mailing Address - Phone:914-949-0575
Mailing Address - Fax:
Practice Address - Street 1:337 MAMARONECK AVE
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10605-1440
Practice Address - Country:US
Practice Address - Phone:914-949-0575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3424332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0371900001Medicare ID - Type Unspecified
NY0371900001Medicare NSC