=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891175261
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TLCARE OF FLORIDA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2015
-----------------------------------------------------
Last Update Date | 03/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5509 GAUR LN
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33811-2637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-937-7596
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5509 GAUR LN
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33811-2637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BOARD MEMBER
-----------------------------------------------------
Name | DR. J MICHAEL WILLIAMS
-----------------------------------------------------
Credential | DBA
-----------------------------------------------------
Telephone | 386-846-1351
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------