=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528492261
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TLC PROVIDERS INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2013
-----------------------------------------------------
Last Update Date | 08/29/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12735 GRAND CROSS LN
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77072-4609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-387-9128
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12735 GRAND CROSS LN
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77072-4609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-387-9128
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MRS. ELLA WILLIAMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 281-387-9128
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------