Healthcare Provider Details

I. General information

NPI: 1750250494
Provider Name (Legal Business Name): ASUR SUPPORTED LIVING SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2025
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5150 E MAIN ST LOWR LEVEL
COLUMBUS OH
43213-2441
US

IV. Provider business mailing address

5150 E MAIN ST LOWR LEVEL
COLUMBUS OH
43213-2441
US

V. Phone/Fax

Practice location:
  • Phone: 614-419-9493
  • Fax:
Mailing address:
  • Phone: 614-419-9493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TAWAIN GORDON JR
Title or Position: MANAGING MEMBER
Credential:
Phone: 614-946-5504