Provider Demographics
NPI:1801404298
Name:ELAINES RESIDENTIAL LLC
Entity Type:Organization
Organization Name:ELAINES RESIDENTIAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:OHIMAI
Authorized Official - Last Name:OJO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-247-2804
Mailing Address - Street 1:1773 E CARDINAL DR
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-6317
Mailing Address - Country:US
Mailing Address - Phone:480-330-4541
Mailing Address - Fax:
Practice Address - Street 1:1773 E CARDINAL DR
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-6317
Practice Address - Country:US
Practice Address - Phone:716-370-5678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-21
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral DisturbancesGroup - Multi-Specialty
No376G00000XNursing Service Related ProvidersNursing Home AdministratorGroup - Multi-Specialty