MEDICARE: TLC PROFESSIONAL SUPPORT SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	343900000X	Non-emergency Medical Transport (VAN)	S5189933	VA
2	251E00000X	Home Health Agency	S5189933	VA

General Provider Information

NPI Number	:	1497154330
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TLC PROFESSIONAL SUPPORT SERVICES, LLC

Provider Business Mailing Address
First Line	:	2321 RIVERSIDE DR
Second Line	:	SUITE 35
City	:	DANVILLE
State	:	VA
Zip	:	24540-4267
Country	:	US
Telephone Number	:	434-799-3500
Fax Number	:	434-799-3525

Provider Business Practice Location Address
First Line	:	2321 RIVERSIDE DR
Second Line	:	SUITE 35
City	:	DANVILLE
State	:	VA
Zip	:	24540-4267
Country	:	US
Telephone Number	:	434-799-3500
Fax Number	:	434-799-3525

Authorized Official
Title or Position	:	MEMBER
Name	:	MRS. LORI WILSON OWENS
Credential	:	RN, BSN
Telephone Number	:	434-799-3500

Provider Enumeration Date	:	08/16/2014
Last Update Date	:	09/30/2014

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