Basic Information
| Provider Information | |||||||||
| NPI: | 1003425133 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EDUCARE COMMUNITY LIVING CORPORATION - NEVADA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 805 N WHITTINGTON PKWY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402227101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026307249 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2258 BRIDLEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891196121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023942100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2020 | ||||||||
| LastUpdateDate: | 07/24/2020 | ||||||||
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| AuthorizedOfficialLastName: | WHOBREY | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | TYLER | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 5026307249 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 07/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |
No ID Information.