1902051154 NPI number — ELDERCARE, INC.

Table of content: (NPI 1902051154)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902051154 NPI number — ELDERCARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELDERCARE, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CALVIN JOHNSON CARE CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902051154
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2810 FRANK SCOTT PARKWAY WEST
Provider Second Line Business Mailing Address:
SUITE 820
Provider Business Mailing Address City Name:
BELLESVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62223-5007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-234-2273
Provider Business Mailing Address Fax Number:
618-234-7777

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
727 NORTH 17TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLEVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62226-6599
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-234-3323
Provider Business Practice Location Address Fax Number:
618-234-9477
Provider Enumeration Date:
12/01/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WOLF
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
618-234-2273

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  1400434197 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 0023309 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BX2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 103025508 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: V255P(657)0911 . This is a "VA (VETERANS' ADMIN)" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com