Healthcare Provider Details

I. General information

NPI: 1083865141
Provider Name (Legal Business Name): ELITE RESIDENTIAL FOR MATURED ADULTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2008
Last Update Date: 10/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 WILSON DR
PROSPER TX
75078-8580
US

IV. Provider business mailing address

160 WILSON DR
PROSPER TX
75078-8580
US

V. Phone/Fax

Practice location:
  • Phone: 972-347-6035
  • Fax: 972-347-6250
Mailing address:
  • Phone: 972-347-6035
  • Fax: 972-347-6250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. VIKKILYNN PREVOST
Title or Position: CO-OWNER/DIRECTOR
Credential: R.D.H
Phone: 972-347-6035