Provider Demographics
NPI:1245602044
Name:CHARLES RESIDENTIAL CARE LLC
Entity Type:Organization
Organization Name:CHARLES RESIDENTIAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:EUGENIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ASOTA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:309-269-0798
Mailing Address - Street 1:15561 W DEVONSHIRE AVE
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-7772
Mailing Address - Country:US
Mailing Address - Phone:623-882-1294
Mailing Address - Fax:
Practice Address - Street 1:15813 W MONROE ST
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-6896
Practice Address - Country:US
Practice Address - Phone:623-882-1294
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-20
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH4681320800000X, 324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility