Provider Demographics
NPI:1295309136
Name:ASUR SUPPORTED LIVING SERVICES LLC
Entity type:Organization
Organization Name:ASUR SUPPORTED LIVING SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TOMIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-795-4422
Mailing Address - Street 1:4328 CANIPE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-5198
Mailing Address - Country:US
Mailing Address - Phone:855-519-2787
Mailing Address - Fax:614-868-1698
Practice Address - Street 1:4328 CANIPE DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-5198
Practice Address - Country:US
Practice Address - Phone:855-519-2787
Practice Address - Fax:614-868-1698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-15
Last Update Date:2021-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251X00000XAgenciesSupports Brokerage
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities