Provider Demographics
NPI:1205023074
Name:ELDERCARE FOR LIFE INC
Entity Type:Organization
Organization Name:ELDERCARE FOR LIFE INC
Other - Org Name:THOROUGHCARE HOME HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDIVORT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-803-1234
Mailing Address - Street 1:PO BOX 429
Mailing Address - Street 2:
Mailing Address - City:HEREFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85615-0429
Mailing Address - Country:US
Mailing Address - Phone:520-803-1234
Mailing Address - Fax:520-803-6552
Practice Address - Street 1:4524 EAST HEREFORD ROAD
Practice Address - Street 2:
Practice Address - City:HEREFORD
Practice Address - State:AZ
Practice Address - Zip Code:85615-9283
Practice Address - Country:US
Practice Address - Phone:520-803-1234
Practice Address - Fax:520-803-6552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZHHA-4118251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1013175512Medicaid
AZ1003082975OtherTHOROUGHCARE REHABILITATION
AZ1205023074Medicaid