1235645185 NPI number — ELITE SENIOR CARE LLC

Table of content: (NPI 1235645185)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235645185 NPI number — ELITE SENIOR CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELITE SENIOR CARE LLC
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:
6
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:
1235645185
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/08/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 888
Provider Second Line Business Mailing Address:
434 HWY 18 BYPASS
Provider Business Mailing Address City Name:
MANILLA
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72442
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-570-0340
Provider Business Mailing Address Fax Number:
844-293-7809

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
434 HWY 18 BYPASS
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANILA
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-570-0340
Provider Business Practice Location Address Fax Number:
844-293-7809
Provider Enumeration Date:
12/14/2017

Additional Information

Authorized Official

Authorized Official Last Name:
HAGOOD
Authorized Official First Name:
LINDSEY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
870-565-5203

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , with the licence number:  222015765 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251J00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 277050732 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 222015765 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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