=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124881180
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELDERCLUB PORT RICHEY INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2024
-----------------------------------------------------
Last Update Date | 02/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9735 US HIGHWAY 19
-----------------------------------------------------
City | PORT RICHEY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34668-3846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-484-7199
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4910 E ADAMO DR UNIT B
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33605-5920
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | VIVAKE ABRAHAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 813-406-0044
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------