Healthcare Provider Details

I. General information

NPI: 1124881180
Provider Name (Legal Business Name): ELDERCLUB PORT RICHEY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2024
Last Update Date: 02/08/2024
Certification Date: 02/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9735 US HIGHWAY 19
PORT RICHEY FL
34668-3846
US

IV. Provider business mailing address

4910 E ADAMO DR UNIT B
TAMPA FL
33605-5920
US

V. Phone/Fax

Practice location:
  • Phone: 727-484-7199
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: VIVAKE ABRAHAM
Title or Position: OWNER
Credential:
Phone: 813-406-0044