Provider Demographics
NPI:1235252826
Name:ELLENDEL ISL LLC
Entity Type:Organization
Organization Name:ELLENDEL ISL LLC
Other - Org Name:ELLENDEL ISL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RHODA
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:TOMICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-627-4101
Mailing Address - Street 1:701 S JAMISON
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501
Mailing Address - Country:US
Mailing Address - Phone:660-627-4101
Mailing Address - Fax:660-665-0185
Practice Address - Street 1:1108 E PATTERSON
Practice Address - Street 2:SUITE 9
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501
Practice Address - Country:US
Practice Address - Phone:660-627-4101
Practice Address - Fax:660-665-0185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2022-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities