=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639561376
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TLC HOME CARE OF ARKANSAS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2015
-----------------------------------------------------
Last Update Date | 03/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 927 PITTMAN RD
-----------------------------------------------------
City | HOT SPRINGS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71913-9006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-802-0404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 927 PITTMAN RD
-----------------------------------------------------
City | HOT SPRINGS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71913-9006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-802-0404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | TABBETHA GILBERT
-----------------------------------------------------
Credential | R.N.
-----------------------------------------------------
Telephone | 501-802-0404
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | R073032
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------