=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194052167
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TBOA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2009
-----------------------------------------------------
Last Update Date | 11/11/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12230 W FOREST HILL BLVD
-----------------------------------------------------
City | WELLINGTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33414-5700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-227-1503
-----------------------------------------------------
Fax | 561-227-1504
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12230 W FOREST HILL BLVD
-----------------------------------------------------
City | WELLINGTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33414-5700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-227-1503
-----------------------------------------------------
Fax | 561-227-1504
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | 0WNER
-----------------------------------------------------
Name | PRISCILLA MANN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-386-5467
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 231031
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------