Provider Demographics
NPI:1679920649
Name:TCBY,LLC
Entity Type:Organization
Organization Name:TCBY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DYANA
Authorized Official - Middle Name:
Authorized Official - Last Name:HELT
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:414-349-7564
Mailing Address - Street 1:528 VIOLET AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53027-1087
Mailing Address - Country:US
Mailing Address - Phone:414-349-7564
Mailing Address - Fax:262-673-0229
Practice Address - Street 1:528 VIOLET AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:WI
Practice Address - Zip Code:53027-1087
Practice Address - Country:US
Practice Address - Phone:414-349-7564
Practice Address - Fax:262-673-0229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-19
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI257126310400000X, 320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1134338882Medicaid