=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356596126
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TENDER HEARTS ENTERPRISES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2008
-----------------------------------------------------
Last Update Date | 11/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 313 BENT WAY LN
-----------------------------------------------------
City | LAKE MARY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32746-4838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-529-4787
-----------------------------------------------------
Fax | 800-546-8385
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 478 E ALTAMONTE DR SUITE 108-205
-----------------------------------------------------
City | ALTAMONTE SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32701-4628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-529-4787
-----------------------------------------------------
Fax | 800-564-8385
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SR. PARTNER
-----------------------------------------------------
Name | MR. TIMOTEO JUAN CHACON
-----------------------------------------------------
Credential | CRNA/ARNP
-----------------------------------------------------
Telephone | 407-529-9292
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 10330
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------