Healthcare Provider Details

I. General information

NPI: 1982471587
Provider Name (Legal Business Name): A1 SUPPORTIVE LIVING AGENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2023
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2614 W CENTRAL AVE
TOLEDO OH
43606-3547
US

IV. Provider business mailing address

PO BOX 70651
TOLEDO OH
43607-0651
US

V. Phone/Fax

Practice location:
  • Phone: 419-699-6769
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. SHAWANDA JOHNSON
Title or Position: OWNER
Credential:
Phone: 419-699-6769