Provider Demographics
NPI:1447644711
Name:ELW HEALTH CENTER LLC
Entity type:Organization
Organization Name:ELW HEALTH CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WAYCHOFF
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:602-284-8994
Mailing Address - Street 1:3202 E GREENWAY RD STE 1619
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-4553
Mailing Address - Country:US
Mailing Address - Phone:602-284-8994
Mailing Address - Fax:602-346-9007
Practice Address - Street 1:3202 E GREENWAY RD STE 1619
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-4553
Practice Address - Country:US
Practice Address - Phone:602-284-8994
Practice Address - Fax:602-346-9007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-25
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP2129305S00000X
AZ37050305S00000X
AZAP2433305S00000X
42847305S00000X
AZ40062305S00000X
AZAP3569305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1417912700OtherCMS