Basic Information
| Provider Information | |||||||||
| NPI: | 1659340222 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TLC REHAB, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 741708 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303741708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523827214 | ||||||||
| FaxNumber: | 3523827781 | ||||||||
| Practice Location | |||||||||
| Address1: | 5481 SW 60TH STREET | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | OCALA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344715638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3528731122 | ||||||||
| FaxNumber: | 3528736841 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 10/18/2021 | ||||||||
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| AuthorizedOfficialLastName: | WALDROP | ||||||||
| AuthorizedOfficialFirstName: | DREAMA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3523827214 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | 10/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | FL | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 883054101 | 05 | FL | MEDICAID |