Provider Demographics
NPI:1003371444
Name:AZARIAN MANOR LLC
Entity Type:Organization
Organization Name:AZARIAN MANOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-597-8891
Mailing Address - Street 1:10325 PLEASANT MOUND DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76108-4927
Mailing Address - Country:US
Mailing Address - Phone:817-597-8891
Mailing Address - Fax:
Practice Address - Street 1:10325 PLEASANT MOUND DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76108-4927
Practice Address - Country:US
Practice Address - Phone:817-597-8891
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities