=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215573753
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELITE CONSULTANT SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2019
-----------------------------------------------------
Last Update Date | 11/19/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 454 ANDERSON RD S STE 162
-----------------------------------------------------
City | ROCK HILL
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29730-3398
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 980-246-5371
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1200 ASHFORD ST
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28214-2347
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-246-5371
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LORI LONG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 970-246-5371
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------