Healthcare Provider Details

I. General information

NPI: 1912388992
Provider Name (Legal Business Name): ELEVATE SENIORS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2015
Last Update Date: 06/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6800 LINCOLN AVE STE 204
BUENA PARK CA
90620-4162
US

IV. Provider business mailing address

6800 LINCOLN AVE STE 204
BUENA PARK CA
90620-4162
US

V. Phone/Fax

Practice location:
  • Phone: 866-888-7078
  • Fax:
Mailing address:
  • Phone: 866-888-7078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: WALTER SIMMONS
Title or Position: OWNER
Credential: MD
Phone: 480-398-5555