Provider Demographics
NPI:1386835874
Name:TLAY HEALTHCARE SERVICES INC.,
Entity Type:Organization
Organization Name:TLAY HEALTHCARE SERVICES INC.,
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:IMELDA
Authorized Official - Middle Name:AZUOMA
Authorized Official - Last Name:NWOGA
Authorized Official - Suffix:
Authorized Official - Credentials:RN, PHD
Authorized Official - Phone:904-794-7601
Mailing Address - Street 1:2802 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-1837
Mailing Address - Country:US
Mailing Address - Phone:904-794-7601
Mailing Address - Fax:904-794-7602
Practice Address - Street 1:2802 N 5TH ST
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-1837
Practice Address - Country:US
Practice Address - Phone:904-794-7601
Practice Address - Fax:904-794-7602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-08
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL692666500Medicaid
FL68-3128Medicare PIN