Healthcare Provider Details

I. General information

NPI: 1285288019
Provider Name (Legal Business Name): ELK BRIDGE HOMES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2019
Last Update Date: 06/28/2024
Certification Date: 06/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13251 W CHAPAROSA WAY
PEORIA AZ
85383-7845
US

IV. Provider business mailing address

13251 W CHAPAROSA WAY
PEORIA AZ
85383-7845
US

V. Phone/Fax

Practice location:
  • Phone: 602-448-2050
  • Fax:
Mailing address:
  • Phone: 602-448-2050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RYAN HOFFMEYER
Title or Position: CEO
Credential: MBA
Phone: 602-448-2050