Provider Demographics
NPI:1487830758
Name:ELBA HEALTHCARE, LLC
Entity Type:Organization
Organization Name:ELBA HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:A
Authorized Official - Last Name:BONACCI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:928-257-4897
Mailing Address - Street 1:1349 E COLTER ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-3048
Mailing Address - Country:US
Mailing Address - Phone:928-257-4897
Mailing Address - Fax:866-534-1701
Practice Address - Street 1:2450 S 4TH AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-8573
Practice Address - Country:US
Practice Address - Phone:928-257-4897
Practice Address - Fax:866-534-1701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3376103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ872003Medicaid
AZ79988Medicare PIN