Provider Demographics
NPI:1205424405
Name:TYLYCE FARMS
Entity type:Organization
Organization Name:TYLYCE FARMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARDE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRUS
Authorized Official - Suffix:
Authorized Official - Credentials:DSD
Authorized Official - Phone:661-797-4018
Mailing Address - Street 1:3231 KEY LARGO DR APT 202
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-5304
Mailing Address - Country:US
Mailing Address - Phone:925-332-8810
Mailing Address - Fax:
Practice Address - Street 1:1937 E 111TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059-2001
Practice Address - Country:US
Practice Address - Phone:661-797-4018
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAGENTA SKY PR
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No167G00000XNursing Service ProvidersLicensed Psychiatric TechnicianGroup - Multi-Specialty