=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952604852
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELITE PERSONAL SERVICES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2010
-----------------------------------------------------
Last Update Date | 12/15/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18020 OHARA DR
-----------------------------------------------------
City | PORT CHARLOTTE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33948-9568
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-740-1460
-----------------------------------------------------
Fax | 941-627-3402
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 380923
-----------------------------------------------------
City | MURDOCK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33938-0923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-740-1460
-----------------------------------------------------
Fax | 941-627-3402
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | TRACEY L WILLIAMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 941-740-1460
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------