=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962202903
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELICORP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2025
-----------------------------------------------------
Last Update Date | 03/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3118 MOCCASIN LN
-----------------------------------------------------
City | AUBREY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76227-1060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-691-0604
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3118 MOCCASIN LN
-----------------------------------------------------
City | AUBREY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76227-1060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-691-0604
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | ELIZABETH E OMODON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 469-691-0604
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 347C00000X
-----------------------------------------------------
Taxonomy Name | Private Vehicle
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 343800000X
-----------------------------------------------------
Taxonomy Name | Secured Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------