MEDICARE: EDUCARE COMMUNITY LIVING CORPORATION - NEVADA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	315P00000X	Intellectual Disabilities Intermediate Care Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073717393
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDUCARE COMMUNITY LIVING CORPORATION - NEVADA

Provider Business Mailing Address
First Line	:	805 N WHITTINGTON PKWY
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40222-5186
Country	:	US
Telephone Number	:	502-394-2100
Fax Number	:

Provider Business Practice Location Address
First Line	:	3829 TUMBLEWEED AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-4541
Country	:	US
Telephone Number	:	502-394-2100
Fax Number	:

Authorized Official
Title or Position	:	PROVIDER ENROLLMENT
Name	:	MR. TIMOTHY TYLER WHOBREY
Credential	:
Telephone Number	:	502-630-7249

Provider Enumeration Date	:	06/12/2007
Last Update Date	:	07/17/2019

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