Provider Demographics
NPI:1033457833
Name:WAY OF LIFE, TCM
Entity Type:Organization
Organization Name:WAY OF LIFE, TCM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-287-6075
Mailing Address - Street 1:1221 W COLONIAL DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-7163
Mailing Address - Country:US
Mailing Address - Phone:407-287-6075
Mailing Address - Fax:407-347-2093
Practice Address - Street 1:1221 W COLONIAL DR
Practice Address - Street 2:SUITE 100
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-7163
Practice Address - Country:US
Practice Address - Phone:407-287-6075
Practice Address - Fax:407-347-2093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-29
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL004873100251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004873100Medicaid