Provider Demographics
NPI:1912688664
Name:IDA MAEZ ADULT LIVING LLC
Entity Type:Organization
Organization Name:IDA MAEZ ADULT LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONISE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-771-9879
Mailing Address - Street 1:100 7TH ST STE 104
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-4800
Mailing Address - Country:US
Mailing Address - Phone:757-771-9879
Mailing Address - Fax:
Practice Address - Street 1:4824 GEORGE WASHINGTON HWY
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23702-2410
Practice Address - Country:US
Practice Address - Phone:757-537-0334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-26
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health