Provider Demographics
NPI:1073997417
Name:ELDERHAUS ADULT DAY PROGRAM, INC
Entity Type:Organization
Organization Name:ELDERHAUS ADULT DAY PROGRAM, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:R
Authorized Official - Last Name:VANDE WALLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-221-0406
Mailing Address - Street 1:6813 S COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-4144
Mailing Address - Country:US
Mailing Address - Phone:970-221-0406
Mailing Address - Fax:
Practice Address - Street 1:6813 S COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-4144
Practice Address - Country:US
Practice Address - Phone:970-221-0406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-15
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04000790Medicaid
CO61522562Medicaid