Provider Demographics
NPI:1164018214
Name:THERAPEUTIC ASSISTED LIVING CORP.
Entity Type:Organization
Organization Name:THERAPEUTIC ASSISTED LIVING CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ALF ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LATASHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:GILYARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-501-8991
Mailing Address - Street 1:25 LYNDENHURST LN
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-9521
Mailing Address - Country:US
Mailing Address - Phone:904-501-8991
Mailing Address - Fax:844-769-0772
Practice Address - Street 1:25 LYNDENHURST LN
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-9521
Practice Address - Country:US
Practice Address - Phone:904-501-8991
Practice Address - Fax:844-769-0772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108468900Medicaid