Provider Demographics
NPI:1891163481
Name:LASALLE TLC ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:LASALLE TLC ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:HAYES
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-501-4756
Mailing Address - Street 1:585 ALLEN DR
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952-4990
Mailing Address - Country:US
Mailing Address - Phone:772-501-4756
Mailing Address - Fax:321-806-4601
Practice Address - Street 1:585 ALLEN DR
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-4990
Practice Address - Country:US
Practice Address - Phone:772-501-4756
Practice Address - Fax:321-806-4601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-13
Last Update Date:2015-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12721310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility