Provider Demographics
NPI:1194150417
Name:AZALEA GARDEN
Entity type:Organization
Organization Name:AZALEA GARDEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE
Authorized Official - Prefix:
Authorized Official - First Name:YALONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-208-8635
Mailing Address - Street 1:413 CULVERT ST
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-1731
Mailing Address - Country:US
Mailing Address - Phone:919-523-5767
Mailing Address - Fax:
Practice Address - Street 1:413 CULVERT ST
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-1731
Practice Address - Country:US
Practice Address - Phone:919-523-5767
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL092659320600000X, 320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities