MEDICARE: TCG HOLDINGS 14, 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	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1891149928
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TCG HOLDINGS 14, LLC

Provider Business Mailing Address
First Line	:	127 N FRANKLIN ST STE 206
Second Line	:
City	:	PORT WASHINGTON
State	:	WI
Zip	:	53074-1948
Country	:	US
Telephone Number	:	262-290-4272
Fax Number	:	262-268-0775

Provider Business Practice Location Address
First Line	:	127 N FRANKLIN ST STE 206
Second Line	:
City	:	PORT WASHINGTON
State	:	WI
Zip	:	53074-1948
Country	:	US
Telephone Number	:	262-290-4272
Fax Number	:	262-268-0775

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. CHARLES PFRANG
Credential	:
Telephone Number	:	262-689-2523

Provider Enumeration Date	:	04/14/2016
Last Update Date	:	04/14/2016

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