Provider Demographics
NPI:1215535265
Name:AZALEA HOME CARE, LLC
Entity Type:Organization
Organization Name:AZALEA HOME CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONOVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:STAFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-862-1914
Mailing Address - Street 1:7624 TANGLE RUSH DR
Mailing Address - Street 2:
Mailing Address - City:GIBSONTON
Mailing Address - State:FL
Mailing Address - Zip Code:33534-5311
Mailing Address - Country:US
Mailing Address - Phone:813-862-1914
Mailing Address - Fax:
Practice Address - Street 1:400 N ASHLEY DR STE 2653
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33602-4300
Practice Address - Country:US
Practice Address - Phone:813-862-1914
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care