Basic Information
| Provider Information | |||||||||
| NPI: | 1912081142 | ||||||||
| 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: | 3523827214 | ||||||||
| Practice Location | |||||||||
| Address1: | 6778 W GULF TO LAKE HWY | ||||||||
| Address2: | |||||||||
| City: | CRYSTAL RIVER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344299348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5279562253 | ||||||||
| FaxNumber: | 3527956065 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 03/17/2022 | ||||||||
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| AuthorizedOfficialLastName: | SCOTT | ||||||||
| AuthorizedOfficialFirstName: | DAPHNE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT OF OUTPATIENT REHABILITAT | ||||||||
| AuthorizedOfficialTelephone: | 4059004729 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | 03/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 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 | 883054100 | 05 | FL | MEDICAID |