Provider Demographics
NPI:1164720371
Name:NELLIS ADULT DAYCARE LLC
Entity Type:Organization
Organization Name:NELLIS ADULT DAYCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECTUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:CAROL
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:765-692-0260
Mailing Address - Street 1:1902 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:CONNERSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47331-2834
Mailing Address - Country:US
Mailing Address - Phone:765-692-0260
Mailing Address - Fax:765-692-0261
Practice Address - Street 1:1902 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:CONNERSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47331-2834
Practice Address - Country:US
Practice Address - Phone:765-692-0260
Practice Address - Fax:765-692-0261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-11
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN201008180A311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201008180AMedicaid