Provider Demographics
NPI:1386179158
Name:T.B.C. VENTURES LLC
Entity Type:Organization
Organization Name:T.B.C. VENTURES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CORNISH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:727-251-8903
Mailing Address - Street 1:493 LAKESIDE PL
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33771-1429
Mailing Address - Country:US
Mailing Address - Phone:727-251-8903
Mailing Address - Fax:
Practice Address - Street 1:1501 N BELCHER RD STE 166
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33765-1339
Practice Address - Country:US
Practice Address - Phone:727-251-8903
Practice Address - Fax:727-216-6999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-28
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT19198225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014745200Medicaid