=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922349539
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TENDER LOVING HOSPITALITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2013
-----------------------------------------------------
Last Update Date | 03/06/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 125 NE 9TH AVE
-----------------------------------------------------
City | CRYSTAL RIVER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34429-4425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-563-1218
-----------------------------------------------------
Fax | 352-563-0511
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 125 NE 9TH AVE
-----------------------------------------------------
City | CRYSTAL RIVER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34429-4425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-563-1218
-----------------------------------------------------
Fax | 352-563-0511
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ADMINISTRATOR
-----------------------------------------------------
Name | MRS. DRUCELLA DIXON DEVAUGHN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 354-563-1218
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 347C00000X
-----------------------------------------------------
Taxonomy Name | Private Vehicle
-----------------------------------------------------
License Number | AL8652
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3104A0625X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility (Mental Illness)
-----------------------------------------------------
License Number | AL8652
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------