=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538909700
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELYSIUM RESIDENTIAL SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2024
-----------------------------------------------------
Last Update Date | 05/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 119 S MAIN ST
-----------------------------------------------------
City | AUBURN
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04210-6631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-316-5110
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 119 S MAIN ST
-----------------------------------------------------
City | AUBURN
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04210-6631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-316-5110
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM MANAGER
-----------------------------------------------------
Name | GEOFFREY WANI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 386-316-5110
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------