Provider Demographics
NPI:1982620050
Name:TLC IMMUNIZATION CLINIC LLC
Entity Type:Organization
Organization Name:TLC IMMUNIZATION CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY OF ORGANIZATION
Authorized Official - Prefix:
Authorized Official - First Name:GRZYBOWSKI
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:ESQUIRE
Authorized Official - Phone:502-301-7408
Mailing Address - Street 1:9721 ORMSBY STATION RD
Mailing Address - Street 2:STE 106
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-4095
Mailing Address - Country:US
Mailing Address - Phone:502-423-1103
Mailing Address - Fax:
Practice Address - Street 1:9721 ORMSBY STATION RD
Practice Address - Street 2:STE 106
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-4095
Practice Address - Country:US
Practice Address - Phone:502-423-1103
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY=========OtherEIN#
IL213924Medicare ID - Type Unspecified