Healthcare Provider Details

I. General information

NPI: 1578993200
Provider Name (Legal Business Name): DELTONA HOME OF TLC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2013
Last Update Date: 11/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1287 DELTONA BLVD
SPRING HILL FL
34606
US

IV. Provider business mailing address

1287 DELTONA BLVD
SPRING HILL FL
34606-4408
US

V. Phone/Fax

Practice location:
  • Phone: 352-683-5255
  • Fax: 352-683-2903
Mailing address:
  • Phone: 352-683-5255
  • Fax: 352-683-2903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number6905138
License Number StateFL

VIII. Authorized Official

Name: MS. CHERI L. LONG
Title or Position: OWNER ADMINSTRATOR
Credential:
Phone: 352-683-5255