Provider Demographics
NPI:1003581240
Name:ELDER LIFE MENTAL HEALTH INC
Entity Type:Organization
Organization Name:ELDER LIFE MENTAL HEALTH INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BETSY
Authorized Official - Middle Name:
Authorized Official - Last Name:GUEVARA RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-830-4316
Mailing Address - Street 1:18140-18142 S.W. 97TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157
Mailing Address - Country:US
Mailing Address - Phone:786-830-4316
Mailing Address - Fax:
Practice Address - Street 1:18140-18142 S.W. 97TH AVENUE
Practice Address - Street 2:
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157
Practice Address - Country:US
Practice Address - Phone:786-830-4316
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-10
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)