Provider Demographics
NPI:1649055849
Name:LA MAZON TRAINING CENTER INCORPORATED
Entity type:Organization
Organization Name:LA MAZON TRAINING CENTER INCORPORATED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GENEVIEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOFIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-201-3317
Mailing Address - Street 1:9515 EREDINE WAY
Mailing Address - Street 2:
Mailing Address - City:BRISTOW
Mailing Address - State:VA
Mailing Address - Zip Code:20136-3517
Mailing Address - Country:US
Mailing Address - Phone:571-201-3317
Mailing Address - Fax:
Practice Address - Street 1:1418 IDAHO ST
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3706
Practice Address - Country:US
Practice Address - Phone:571-201-3317
Practice Address - Fax:866-985-4040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-28
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities