Provider Demographics
NPI:1881025005
Name:ELM TREE LODGE
Entity Type:Organization
Organization Name:ELM TREE LODGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARGE
Authorized Official - Middle Name:
Authorized Official - Last Name:COFFEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-845-0609
Mailing Address - Street 1:6205 VIOLA LN
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34653-1701
Mailing Address - Country:US
Mailing Address - Phone:727-845-0609
Mailing Address - Fax:
Practice Address - Street 1:6205 VIOLA LANE
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34653
Practice Address - Country:US
Practice Address - Phone:727-845-0609
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ASSISTED LIVING OF PASCO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-12-13
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL8589305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization