Provider Demographics
NPI:1649409657
Name:ESTATE LIVING PLACE INC
Entity Type:Organization
Organization Name:ESTATE LIVING PLACE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:J
Authorized Official - Last Name:MALIYIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-523-1024
Mailing Address - Street 1:5111 FINNHORSE DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-2563
Mailing Address - Country:US
Mailing Address - Phone:972-523-1024
Mailing Address - Fax:
Practice Address - Street 1:537 ESTATE DR
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-6712
Practice Address - Country:US
Practice Address - Phone:972-523-1024
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-11
Last Update Date:2009-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care