1588141204 NPI number — ELEVATING HEALTH ENTERPRISES LTD CO

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588141204 NPI number — ELEVATING HEALTH ENTERPRISES LTD CO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELEVATING HEALTH ENTERPRISES LTD CO
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:
Provider Other Organization Name Type Code:
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:
1588141204
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 673111
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARIETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30006-0052
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4949 OAKDALE RD SE APT 813
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SMYRNA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30080-7173
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-205-0208
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/25/2018

Additional Information

Authorized Official

Authorized Official Last Name:
BLEDSOE
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
856-404-7651

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CHIR009678 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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