Provider Demographics
NPI:1578993200
Name:DELTONA HOME OF TLC INC.
Entity Type:Organization
Organization Name:DELTONA HOME OF TLC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER ADMINSTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CHERI
Authorized Official - Middle Name:L
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-683-5255
Mailing Address - Street 1:1287 DELTONA BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34606-4408
Mailing Address - Country:US
Mailing Address - Phone:352-683-5255
Mailing Address - Fax:352-683-2903
Practice Address - Street 1:1287 DELTONA BLVD
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34606
Practice Address - Country:US
Practice Address - Phone:352-683-5255
Practice Address - Fax:352-683-2903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-15
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6905138320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL691238996Medicaid
FL691238998Medicaid
FL1414178Medicaid