Provider Demographics
NPI:1386288041
Name:AZAREL COMMUNITY SUPPORT, LLC
Entity type:Organization
Organization Name:AZAREL COMMUNITY SUPPORT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TACOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-928-3054
Mailing Address - Street 1:112 BRANDON RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23224-1212
Mailing Address - Country:US
Mailing Address - Phone:804-928-3054
Mailing Address - Fax:804-231-6129
Practice Address - Street 1:112 BRANDON RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23224-1212
Practice Address - Country:US
Practice Address - Phone:804-928-3054
Practice Address - Fax:804-231-6129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2920OtherVIRGINIA DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL SERVICES