Provider Demographics
NPI:1417251638
Name:TLC PROVIDERS INC
Entity Type:Organization
Organization Name:TLC PROVIDERS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:BOOKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-236-0073
Mailing Address - Street 1:8317 FRONT BEACH RD
Mailing Address - Street 2:SUITE 29A1
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32407-4885
Mailing Address - Country:US
Mailing Address - Phone:850-236-0073
Mailing Address - Fax:850-236-0403
Practice Address - Street 1:8317 FRONT BEACH RD
Practice Address - Street 2:SUITE 29A1
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32407-4885
Practice Address - Country:US
Practice Address - Phone:850-236-0073
Practice Address - Fax:850-236-0403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL679970198Medicaid
FL679970196Medicaid