Provider Demographics
NPI:1629001425
Name:TLC PEDIATRIC & ADOLESCENT MEDICINE, P.A.
Entity Type:Organization
Organization Name:TLC PEDIATRIC & ADOLESCENT MEDICINE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:REYNOLDS-LACY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:407-380-9115
Mailing Address - Street 1:1834 N ALAFAYA TRL
Mailing Address - Street 2:SUITE A
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32826-4743
Mailing Address - Country:US
Mailing Address - Phone:407-380-9115
Mailing Address - Fax:407-380-9189
Practice Address - Street 1:1834 N ALAFAYA TRL
Practice Address - Street 2:SUITE A
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32826-4743
Practice Address - Country:US
Practice Address - Phone:407-380-9115
Practice Address - Fax:407-380-9189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK8880Medicaid
FL97689OtherBCBS
FLK8880Medicaid