Healthcare Provider Details

I. General information

NPI: 1114835311
Provider Name (Legal Business Name): MEDIORA ELEVUS DIVERSIFIED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2026
Last Update Date: 08/29/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

388 CANTERBURY RD
BUSHKILL PA
18324-9055
US

IV. Provider business mailing address

30 S 15TH ST STE 1550
PHILADELPHIA PA
19102-4806
US

V. Phone/Fax

Practice location:
  • Phone: 215-933-2562
  • Fax:
Mailing address:
  • Phone: 215-933-2562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: RASHIDAH JACKSON
Title or Position: CEO
Credential: LPN
Phone: 856-676-1946