MEDICARE: ANTONINA'S TLC, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	16602	FL

General Provider Information

NPI Number	:	1124097746
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANTONINA'S TLC, INC.

Provider Business Mailing Address
First Line	:	301 174TH ST
Second Line	:	1903
City	:	SUNNY ISLES BEACH
State	:	FL
Zip	:	33160-3206
Country	:	US
Telephone Number	:	305-705-9366
Fax Number	:	305-705-9366

Provider Business Practice Location Address
First Line	:	301 174TH ST
Second Line	:	1903
City	:	SUNNY ISLES BEACH
State	:	FL
Zip	:	33160-3206
Country	:	US
Telephone Number	:	305-915-7375
Fax Number	:	305-705-9366

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. ANTONINA BRICHOK
Credential	:	P.T.
Telephone Number	:	305-705-9366

Provider Enumeration Date	:	03/16/2006
Last Update Date	:	08/22/2020

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