Healthcare Provider Details

I. General information

NPI: 1164018214
Provider Name (Legal Business Name): THERAPEUTIC ASSISTED LIVING CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2020
Last Update Date: 12/14/2020
Certification Date: 12/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 LYNDENHURST LN
PALM COAST FL
32137-9521
US

IV. Provider business mailing address

25 LYNDENHURST LN
PALM COAST FL
32137-9521
US

V. Phone/Fax

Practice location:
  • Phone: 904-501-8991
  • Fax: 844-769-0772
Mailing address:
  • Phone: 904-501-8991
  • Fax: 844-769-0772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State

VIII. Authorized Official

Name: LATASHA D GILYARD
Title or Position: ALF ADMINISTRATOR
Credential:
Phone: 904-501-8991