Provider Demographics
NPI:1376027094
Name:ELITE ASSISTED LIVING HOME LLC
Entity Type:Organization
Organization Name:ELITE ASSISTED LIVING HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DENISA
Authorized Official - Middle Name:
Authorized Official - Last Name:KAPORALIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-339-3617
Mailing Address - Street 1:15755 W SHANGRI LA RD
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85379-4801
Mailing Address - Country:US
Mailing Address - Phone:623-584-5580
Mailing Address - Fax:623-399-6561
Practice Address - Street 1:15755 W SHANGRI LA RD
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85379-4801
Practice Address - Country:US
Practice Address - Phone:623-584-5580
Practice Address - Fax:623-399-6561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ099337Medicaid