=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902200249
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TLC COMPANIONS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2014
-----------------------------------------------------
Last Update Date | 10/15/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1407 LEESON AVE
-----------------------------------------------------
City | CADILLAC
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49601-9098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-942-3705
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1407 LEESON AVE
-----------------------------------------------------
City | CADILLAC
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49601-9098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-942-3705
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING DIRECTOR
-----------------------------------------------------
Name | MARK ALLEN KORNACKI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 231-942-3705
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------