=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386083426
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELIM SENIOR SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2013
-----------------------------------------------------
Last Update Date | 06/26/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18787 CARLTON AVE
-----------------------------------------------------
City | CASTRO VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94546-2905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-885-0557
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18787 CARLTON AVE
-----------------------------------------------------
City | CASTRO VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94546-2905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-818-8101
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LLC MEMBER
-----------------------------------------------------
Name | MS. ECATERINA TET
-----------------------------------------------------
Credential | LVN
-----------------------------------------------------
Telephone | 925-768-3031
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311Z00000X
-----------------------------------------------------
Taxonomy Name | Custodial Care Facility
-----------------------------------------------------
License Number | 075600223
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 311Z00000X
-----------------------------------------------------
Taxonomy Name | Custodial Care Facility
-----------------------------------------------------
License Number | 075601505
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 311Z00000X
-----------------------------------------------------
Taxonomy Name | Custodial Care Facility
-----------------------------------------------------
License Number | 015601014
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------