Provider Demographics
NPI:1972120954
Name:ELITE INDIGO
Entity type:Organization
Organization Name:ELITE INDIGO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAVARION
Authorized Official - Middle Name:TERRELL
Authorized Official - Last Name:NIX
Authorized Official - Suffix:
Authorized Official - Credentials:MS,LPN-IVT, DCP
Authorized Official - Phone:432-978-6035
Mailing Address - Street 1:310 SEMINOLE CIR
Mailing Address - Street 2:
Mailing Address - City:TERRY
Mailing Address - State:MS
Mailing Address - Zip Code:39170-8787
Mailing Address - Country:US
Mailing Address - Phone:432-978-6035
Mailing Address - Fax:
Practice Address - Street 1:310 SEMINOLE CIR
Practice Address - Street 2:
Practice Address - City:TERRY
Practice Address - State:MS
Practice Address - Zip Code:39170-8787
Practice Address - Country:US
Practice Address - Phone:432-978-6035
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-25
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health