=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386942027
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AUDREY'S TLC II
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2011
-----------------------------------------------------
Last Update Date | 03/04/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6808 MERION PL
-----------------------------------------------------
City | N LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33068-3706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 754-368-9993
-----------------------------------------------------
Fax | 754-368-9993
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6808 MERION PL
-----------------------------------------------------
City | N LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33068-3706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 754-368-9993
-----------------------------------------------------
Fax | 754-368-9993
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ADMINISTRATOR
-----------------------------------------------------
Name | AUDREY BEVERLY THORPE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 754-368-9993
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3104A0625X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility (Mental Illness)
-----------------------------------------------------
License Number | AL11943
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------