Healthcare Provider Details

I. General information

NPI: 1538047089
Provider Name (Legal Business Name): TTOLBERT 1964 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2025
Last Update Date: 08/23/2025
Certification Date: 08/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N SAINT CLAIR ST APT 2308
TOLEDO OH
43604-1555
US

IV. Provider business mailing address

200 N SAINT CLAIR ST APT 2308
TOLEDO OH
43604-1555
US

V. Phone/Fax

Practice location:
  • Phone: 567-318-9604
  • Fax: 567-318-9604
Mailing address:
  • Phone: 567-318-9604
  • Fax: 567-318-9604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: TOMMY TERRELL JONES
Title or Position: OWNER
Credential:
Phone: 567-318-9604