Provider Demographics
NPI:1417428806
Name:TA FRIENDLY HELPERS
Entity Type:Organization
Organization Name:TA FRIENDLY HELPERS
Other - Org Name:TA FRIENDLY HELPERS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:BSW
Authorized Official - Phone:813-863-5113
Mailing Address - Street 1:12316 BALLENTRAE FOREST DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-9339
Mailing Address - Country:US
Mailing Address - Phone:813-863-5113
Mailing Address - Fax:
Practice Address - Street 1:12316 BALLENTRAE FOREST DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33579-9339
Practice Address - Country:US
Practice Address - Phone:813-863-5113
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-10
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Yes253Z00000XAgenciesIn Home Supportive Care
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015952700Medicaid