Healthcare Provider Details

I. General information

NPI: 1497666465
Provider Name (Legal Business Name): ELEVATE ADULT WELLNESS CLUB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14110 TELEGRAPH RD
DETROIT MI
48239-2865
US

IV. Provider business mailing address

5806 N 191ST DR
LITCHFIELD PARK AZ
85340-5812
US

V. Phone/Fax

Practice location:
  • Phone: 623-980-8107
  • Fax:
Mailing address:
  • Phone: 623-980-8107
  • 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: MR. KENNETH WORTHY II
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 623-980-8107