Basic Information
Provider Information | |||||||||
NPI: | 1699757708 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ELDERCARE INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ELDERCARE OF ALTON | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2810 FRANK SCOTT PKWY W | ||||||||
Address2: | SUITE 820 | ||||||||
City: | BELLEVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 622235007 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6182342273 | ||||||||
FaxNumber: | 6182347777 | ||||||||
Practice Location | |||||||||
Address1: | 3523 WICKENHAUSER AVE | ||||||||
Address2: |   | ||||||||
City: | ALTON | ||||||||
State: | IL | ||||||||
PostalCode: | 620022199 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6184658887 | ||||||||
FaxNumber: | 6184651811 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/15/2005 | ||||||||
LastUpdateDate: | 04/20/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WOLF | ||||||||
AuthorizedOfficialFirstName: | STEVEN | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 6182342273 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 14D06992611 | IL | N |   | Laboratories | Clinical Medical Laboratory |   | 314000000X | 0023317 | IL | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.