Healthcare Provider Details

I. General information

NPI: 1801404298
Provider Name (Legal Business Name): ELAINES RESIDENTIAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2020
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1773 E CARDINAL DR
CASA GRANDE AZ
85122-6317
US

IV. Provider business mailing address

1773 E CARDINAL DR
CASA GRANDE AZ
85122-6317
US

V. Phone/Fax

Practice location:
  • Phone: 716-370-5678
  • Fax:
Mailing address:
  • Phone: 480-330-4541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number
License Number State

VIII. Authorized Official

Name: MR. ANDREW OHIMAI OJO
Title or Position: ADMINISTRATOR
Credential:
Phone: 928-247-2804