Provider Demographics
NPI:1982137154
Name:ELVENSTAR, MCRANDON
Entity Type:Individual
Prefix:
First Name:MCRANDON
Middle Name:
Last Name:ELVENSTAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7817 SURREYWOOD PL
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28270-2161
Mailing Address - Country:US
Mailing Address - Phone:704-651-2509
Mailing Address - Fax:
Practice Address - Street 1:204 E OLD HIGHWAY 74
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-8122
Practice Address - Country:US
Practice Address - Phone:704-283-3066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-05
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2617314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility