Provider Demographics
NPI:1285183087
Name:ELITE SENIOR CARE-NORTH ARKANSAS LLC
Entity Type:Organization
Organization Name:ELITE SENIOR CARE-NORTH ARKANSAS LLC
Other - Org Name:ALLHEART SENIOR CARE-NORTH ARKANSAS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-435-2123
Mailing Address - Street 1:P. O. BOX 218
Mailing Address - Street 2:6289 HWY 62 WEST /
Mailing Address - City:GASSVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72635
Mailing Address - Country:US
Mailing Address - Phone:870-435-2123
Mailing Address - Fax:
Practice Address - Street 1:6289 HWY 62W
Practice Address - Street 2:
Practice Address - City:GASSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72635
Practice Address - Country:US
Practice Address - Phone:870-435-2123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-22
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR215139765251B00000X
253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR207843797Medicaid
AR206177732Medicaid
AR215139765Medicaid
AR205557757Medicaid