MEDICARE: ELKS AIDMORE, INC.

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	253J00000X	Foster Care Agency	C1000Q010056	GA

General Provider Information

NPI Number	:	1316209083
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELKS AIDMORE, INC.

Provider Business Mailing Address
First Line	:	2394 MORRISON RD SW
Second Line	:
City	:	CONYERS
State	:	GA
Zip	:	30094-3330
Country	:	US
Telephone Number	:	770-483-3535
Fax Number	:	770-483-5696

Provider Business Practice Location Address
First Line	:	2394 MORRISON RD SW
Second Line	:
City	:	CONYERS
State	:	GA
Zip	:	30094-3330
Country	:	US
Telephone Number	:	770-483-3535
Fax Number	:	770-483-5696

Authorized Official
Title or Position	:	CEO
Name	:	MR. ABE MEYER WILKINSON
Credential	:
Telephone Number	:	770-483-3535

Provider Enumeration Date	:	06/08/2012
Last Update Date	:	06/08/2012

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Directions to “ELKS AIDMORE, INC. ” Practice Location

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