MEDICARE: AUDREY'S TLC II

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	3104A0625X	Assisted Living Facility (Mental Illness)	AL11943	FL

General Provider Information

NPI Number	:	1386942027
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUDREY'S TLC II

Provider Business Mailing Address
First Line	:	6808 MERION PL
Second Line	:
City	:	N LAUDERDALE
State	:	FL
Zip	:	33068-3706
Country	:	US
Telephone Number	:	754-368-9993
Fax Number	:	754-368-9993

Provider Business Practice Location Address
First Line	:	6808 MERION PL
Second Line	:
City	:	N LAUDERDALE
State	:	FL
Zip	:	33068-3706
Country	:	US
Telephone Number	:	754-368-9993
Fax Number	:	754-368-9993

Authorized Official
Title or Position	:	OWNER/ADMINISTRATOR
Name	:	AUDREY BEVERLY THORPE
Credential	:
Telephone Number	:	754-368-9993

Provider Enumeration Date	:	03/04/2011
Last Update Date	:	03/04/2011

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