Provider Demographics
NPI:1154115400
Name:ELEGANT RESIDENTIAL LIVING INC
Entity type:Organization
Organization Name:ELEGANT RESIDENTIAL LIVING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JODIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KATSILOMETES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-478-9400
Mailing Address - Street 1:1256 WRIGHT AVE BLDG 1234
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-5084
Mailing Address - Country:US
Mailing Address - Phone:208-478-9400
Mailing Address - Fax:
Practice Address - Street 1:1256 WRIGHT AVE BLDG 1234
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83202-5084
Practice Address - Country:US
Practice Address - Phone:208-478-9400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-09
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility