Healthcare Provider Details

I. General information

NPI: 1447708771
Provider Name (Legal Business Name): ELCM MANOR SOUTH MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2016
Last Update Date: 09/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 HARBOR VIEW RD
SOUTH BURLINGTON VT
05403-7850
US

IV. Provider business mailing address

14241 DALLAS PKWY STE 650
DALLAS TX
75254-2953
US

V. Phone/Fax

Practice location:
  • Phone: 802-863-7897
  • Fax: 802-863-9728
Mailing address:
  • Phone: 214-417-4588
  • Fax: 214-594-9930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number StateVT

VIII. Authorized Official

Name: MR. PAUL BOETHEL
Title or Position: PRINCIPAL
Credential:
Phone: 972-728-8739