1447593496 NPI number — ELITE COMMUNITY SERVICES, LLC

Table of content: (NPI 1447593496)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447593496 NPI number — ELITE COMMUNITY SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELITE COMMUNITY SERVICES, 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:
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:
1447593496
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3651 E. BASELINE RD.
Provider Second Line Business Mailing Address:
#E-222
Provider Business Mailing Address City Name:
GILBERT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85234
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-558-1275
Provider Business Mailing Address Fax Number:
480-558-1276

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3651 E BASELINE RD
Provider Second Line Business Practice Location Address:
#E-222
Provider Business Practice Location Address City Name:
GILBERT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85234-2689
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-558-1275
Provider Business Practice Location Address Fax Number:
480-558-1276
Provider Enumeration Date:
03/28/2013

Additional Information

Authorized Official

Authorized Official Last Name:
APPENZELLER
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
Authorized Official Title or Position:
C.O.O.
Authorized Official Telephone Number:
888-558-1275

Provider Taxonomy Codes

  • Taxonomy code: 253Z00000X , with the licence number:  L-1449513-8 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 253Z00000X , with the licence number: NV20121451557 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 385750 . This is a "AHCCCS - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM CERTIFICATION" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: RFQVA DDD710000 . This is a "AZ DEPT. OF ECONOMIC SECURITY CERTIFICATE FOR HOME AND COMMUNITY BASED SERVICES" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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