Healthcare Provider Details

I. General information

NPI: 1275252603
Provider Name (Legal Business Name): TLC UNDERGROUND TRUCKING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2022
Last Update Date: 08/29/2022
Certification Date: 08/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3863 HIGHWAY 138 SE UNIT 246
STOCKBRIDGE GA
30281-4143
US

IV. Provider business mailing address

904 STONE RDG
MCDONOUGH GA
30252-5010
US

V. Phone/Fax

Practice location:
  • Phone: 404-216-5156
  • Fax:
Mailing address:
  • Phone: 404-216-5156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TARSHAONTE CAUSEY
Title or Position: OWNER
Credential:
Phone: 404-216-5156