MEDICARE: ELSYOFF CARE CENTER LLC

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	261QD1600X	Developmental Disabilities Clinic/Center

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	:	1619578192
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELSYOFF CARE CENTER LLC

Provider Business Mailing Address
First Line	:	1727 NW 19TH TER
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33993-4915
Country	:	US
Telephone Number	:	239-312-8316
Fax Number	:	239-312-8320

Provider Business Practice Location Address
First Line	:	1727 NW 19TH TER
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33993-4915
Country	:	US
Telephone Number	:	239-312-8316
Fax Number	:	239-312-8320

Authorized Official
Title or Position	:	OWNER
Name	:	MAILIN FREEMAN
Credential	:
Telephone Number	:	239-312-8316

Provider Enumeration Date	:	11/02/2020
Last Update Date	:	11/02/2020

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