Provider Demographics
NPI:1699757708
Name:ELDERCARE INC
Entity type:Organization
Organization Name:ELDERCARE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:3523 WICKENHAUSER AVE
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-2199
Practice Address - Country:US
Practice Address - Phone:618-465-8887
Practice Address - Fax:618-465-1811
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
IL14D06992611291U00000X
IL0023317314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid
IL=========002Medicaid
0263120002Medicare NSC
145427Medicare ID - Type Unspecified