Provider Demographics
NPI:1568459014
Name:TLG INC
Entity Type:Organization
Organization Name:TLG INC
Other - Org Name:COCOS BOUTIQUE & SPECIALTY SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COMPANY PRESIDENT OWNER FITTER
Authorized Official - Prefix:MRS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:HESTER
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:CERTIFIED FITTER
Authorized Official - Phone:219-836-0011
Mailing Address - Street 1:921 RIDGE RD
Mailing Address - Street 2:C2
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-1739
Mailing Address - Country:US
Mailing Address - Phone:219-836-0011
Mailing Address - Fax:219-836-0140
Practice Address - Street 1:921 RIDGE RD
Practice Address - Street 2:C2
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1739
Practice Address - Country:US
Practice Address - Phone:219-836-0011
Practice Address - Fax:219-836-0140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN4868850001Medicare ID - Type Unspecified
IL4868850001Medicare ID - Type Unspecified