Provider Demographics
NPI:1508915299
Name:AZARE
Entity Type:Organization
Organization Name:AZARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MASHBURN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-777-4948
Mailing Address - Street 1:4243 HIGHWAY D
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-9302
Mailing Address - Country:US
Mailing Address - Phone:417-777-4948
Mailing Address - Fax:
Practice Address - Street 1:4243 HIGHWAY D
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-9302
Practice Address - Country:US
Practice Address - Phone:417-777-4948
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO14209362320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities