Basic Information
| Provider Information | |||||||||
| NPI: | 1902051154 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELDERCARE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CALVIN JOHNSON CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2810 FRANK SCOTT PARKWAY WEST | ||||||||
| Address2: | SUITE 820 | ||||||||
| City: | BELLESVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622235007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182342273 | ||||||||
| FaxNumber: | 6182347777 | ||||||||
| Practice Location | |||||||||
| Address1: | 727 NORTH 17TH STREET | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622266599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182343323 | ||||||||
| FaxNumber: | 6182349477 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2008 | ||||||||
| LastUpdateDate: | 08/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | WOLF | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6182342273 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 1400434197 | IL | N | Laboratories | Clinical Medical Laboratory | 332BX2000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies | 314000000X | 0023309 | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 103025508 | 05 | MO | MEDICAID | V255P(657)0911 | 01 | VA (VETERANS' ADMIN) | OTHER |