MEDICARE: TLC PEDIATRIC & ADOLESCENT MEDICINE, P.A.

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	208000000X	Pediatrics Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	97689	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1629001425
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TLC PEDIATRIC & ADOLESCENT MEDICINE, P.A.

Provider Business Mailing Address
First Line	:	1834 N ALAFAYA TRL
Second Line	:	SUITE A
City	:	ORLANDO
State	:	FL
Zip	:	32826-4743
Country	:	US
Telephone Number	:	407-380-9115
Fax Number	:	407-380-9189

Provider Business Practice Location Address
First Line	:	1834 N ALAFAYA TRL
Second Line	:	SUITE A
City	:	ORLANDO
State	:	FL
Zip	:	32826-4743
Country	:	US
Telephone Number	:	407-380-9115
Fax Number	:	407-380-9189

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	DEBBIE REYNOLDS-LACY
Credential	:	RN
Telephone Number	:	407-380-9115

Provider Enumeration Date	:	07/08/2006
Last Update Date	:	08/22/2020

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Directions to “TLC PEDIATRIC & ADOLESCENT MEDICINE, P.A. ” Practice Location

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