Healthcare Provider Details

I. General information

NPI: 1679920649
Provider Name (Legal Business Name): TCBY,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2016
Last Update Date: 05/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

528 VIOLET AVE
HARTFORD WI
53027-1087
US

IV. Provider business mailing address

528 VIOLET AVE
HARTFORD WI
53027-1087
US

V. Phone/Fax

Practice location:
  • Phone: 414-349-7564
  • Fax: 262-673-0229
Mailing address:
  • Phone: 414-349-7564
  • Fax: 262-673-0229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number257126
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number257126
License Number StateWI

VIII. Authorized Official

Name: DYANA HELT
Title or Position: PRESIDENT
Credential: OT
Phone: 414-349-7564