=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164018214
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THERAPEUTIC ASSISTED LIVING CORP.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2020
-----------------------------------------------------
Last Update Date | 12/14/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25 LYNDENHURST LN
-----------------------------------------------------
City | PALM COAST
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32137-9521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-501-8991
-----------------------------------------------------
Fax | 844-769-0772
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25 LYNDENHURST LN
-----------------------------------------------------
City | PALM COAST
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32137-9521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-501-8991
-----------------------------------------------------
Fax | 844-769-0772
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ALF ADMINISTRATOR
-----------------------------------------------------
Name | LATASHA D GILYARD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-501-8991
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3104A0625X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility (Mental Illness)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------