Provider Demographics
NPI:1316711948
Name:ALTERNATIVE LIVING RESIDENCE
Entity type:Organization
Organization Name:ALTERNATIVE LIVING RESIDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:T
Authorized Official - Last Name:JANNAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-477-8097
Mailing Address - Street 1:4 FLEWELLEN DR
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-7829
Mailing Address - Country:US
Mailing Address - Phone:571-477-8097
Mailing Address - Fax:
Practice Address - Street 1:14090 BIG CREST LN APT 207
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-5531
Practice Address - Country:US
Practice Address - Phone:157-477-8097
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-14
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care