Healthcare Provider Details

I. General information

NPI: 1194150417
Provider Name (Legal Business Name): AZALEA GARDEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2013
Last Update Date: 09/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 CULVERT ST
APEX NC
27502-1731
US

IV. Provider business mailing address

413 CULVERT ST
APEX NC
27502-1731
US

V. Phone/Fax

Practice location:
  • Phone: 919-523-5767
  • Fax:
Mailing address:
  • Phone: 919-523-5767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberMHL092659
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License NumberMHL092659
License Number StateNC

VIII. Authorized Official

Name: YALONDA COLEMAN
Title or Position: ADMINISTRATIVE
Credential:
Phone: 919-208-8635