1164018214 NPI number — THERAPEUTIC ASSISTED LIVING CORP.

Table of content: (NPI 1164018214)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164018214 NPI number — THERAPEUTIC ASSISTED LIVING CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THERAPEUTIC ASSISTED LIVING CORP.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164018214
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25 LYNDENHURST LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALM COAST
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32137-9521
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-501-8991
Provider Business Mailing Address Fax Number:
844-769-0772

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 LYNDENHURST LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALM COAST
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32137-9521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-501-8991
Provider Business Practice Location Address Fax Number:
844-769-0772
Provider Enumeration Date:
12/14/2020

Additional Information

Authorized Official

Authorized Official Last Name:
GILYARD
Authorized Official First Name:
LATASHA
Authorized Official Middle Name:
D
Authorized Official Title or Position:
ALF ADMINISTRATOR
Authorized Official Telephone Number:
904-501-8991

Provider Taxonomy Codes

  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3104A0625X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 108468900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com