Provider Demographics
NPI:1720062367
Name:TLC FAMILY PRACTICE
Entity Type:Organization
Organization Name:TLC FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:R
Authorized Official - Last Name:LEBEAU
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:480-632-7400
Mailing Address - Street 1:428 S GILBERT RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-2263
Mailing Address - Country:US
Mailing Address - Phone:480-632-7400
Mailing Address - Fax:480-632-8400
Practice Address - Street 1:428 S GILBERT RD
Practice Address - Street 2:SUITE 101
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-2263
Practice Address - Country:US
Practice Address - Phone:480-632-7400
Practice Address - Fax:480-632-8400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2822207Q00000X
AZ1862207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E44491Medicare UPIN
F67675Medicare UPIN
AZ65222Medicare ID - Type Unspecified