Provider Demographics
NPI:1083865141
Name:ELITE RESIDENTIAL FOR MATURED ADULTS
Entity Type:Organization
Organization Name:ELITE RESIDENTIAL FOR MATURED ADULTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:VIKKILYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:PREVOST
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:972-347-6035
Mailing Address - Street 1:160 WILSON DR
Mailing Address - Street 2:
Mailing Address - City:PROSPER
Mailing Address - State:TX
Mailing Address - Zip Code:75078-8580
Mailing Address - Country:US
Mailing Address - Phone:972-347-6035
Mailing Address - Fax:972-347-6250
Practice Address - Street 1:160 WILSON DR
Practice Address - Street 2:
Practice Address - City:PROSPER
Practice Address - State:TX
Practice Address - Zip Code:75078-8580
Practice Address - Country:US
Practice Address - Phone:972-347-6035
Practice Address - Fax:972-347-6250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-08
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities