Provider Demographics
NPI:1982471587
Name:A1 SUPPORTIVE LIVING AGENCY
Entity type:Organization
Organization Name:A1 SUPPORTIVE LIVING AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAWANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-699-6769
Mailing Address - Street 1:PO BOX 70651
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43607-0651
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2614 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3547
Practice Address - Country:US
Practice Address - Phone:419-699-6769
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-05
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No253Z00000XAgenciesIn Home Supportive Care
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility