Provider Demographics
NPI:1982686093
Name:ELDERCARE INC
Entity Type:Organization
Organization Name:ELDERCARE INC
Other - Org Name:CALVIN JOHNSON CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:WOLF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-234-2273
Mailing Address - Street 1:2810 FRANK SCOTT PKWY W
Mailing Address - Street 2:SUITE 820
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-5007
Mailing Address - Country:US
Mailing Address - Phone:618-234-2273
Mailing Address - Fax:618-234-7777
Practice Address - Street 1:727 N 17TH ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-6552
Practice Address - Country:US
Practice Address - Phone:618-234-3323
Practice Address - Fax:618-234-9477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-15
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0023309314000000X
IL291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
V255P6570911OtherVA VETERANS ADMIN
V255P6570911OtherVA VETERANS ADMIN
145290Medicare ID - Type Unspecified
0263120001Medicare NSC
145290Medicare Oscar/Certification