MEDICARE: TTOLBERT 1964 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	251S00000X	Community/Behavioral Health Agency
2	385HR2060X	Child Intellectual and/or Developmental Disabilities Respite Care

General Provider Information

NPI Number	:	1538047089
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TTOLBERT 1964 LLC

Provider Business Mailing Address
First Line	:	200 N SAINT CLAIR ST APT 2308
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43604-1555
Country	:	US
Telephone Number	:	567-318-9604
Fax Number	:	567-318-9604

Provider Business Practice Location Address
First Line	:	200 N SAINT CLAIR ST APT 2308
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43604-1555
Country	:	US
Telephone Number	:	567-318-9604
Fax Number	:	567-318-9604

Authorized Official
Title or Position	:	OWNER
Name	:	TOMMY TERRELL JONES
Credential	:
Telephone Number	:	567-318-9604

Provider Enumeration Date	:	08/23/2025
Last Update Date	:	08/23/2025

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