=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851989420
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELITE CARE PSA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2021
-----------------------------------------------------
Last Update Date | 07/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 250 W 80TH PL
-----------------------------------------------------
City | MERRILLVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46410-5430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-648-2125
-----------------------------------------------------
Fax | 219-472-8468
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 568 S WASHINGTON ST
-----------------------------------------------------
City | NAPERVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60540-6843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-548-9500
-----------------------------------------------------
Fax | 630-548-0541
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER
-----------------------------------------------------
Name | JOHN MASTRANGELI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 630-505-3623
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------