MEDICARE: ELITE ADOLESCENT CARE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	323P00000X	Psychiatric Residential Treatment Facility	MHL-041-1082	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326412578
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELITE ADOLESCENT CARE, INC.

Provider Business Mailing Address
First Line	:	PO BOX 38338
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27408-8338
Country	:	US
Telephone Number	:	336-763-7287
Fax Number	:

Provider Business Practice Location Address
First Line	:	4501 OLD BATTLEGROUND RD
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27410-9352
Country	:	US
Telephone Number	:	336-763-7287
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. MICHAEL A. CAMPI
Credential	:
Telephone Number	:	843-729-6072

Provider Enumeration Date	:	11/25/2015
Last Update Date	:	05/06/2016

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