Provider Demographics
NPI:1447708771
Name:ELCM MANOR SOUTH MANAGEMENT LLC
Entity type:Organization
Organization Name:ELCM MANOR SOUTH MANAGEMENT LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOETHEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-728-8739
Mailing Address - Street 1:14241 DALLAS PKWY STE 650
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-2953
Mailing Address - Country:US
Mailing Address - Phone:214-417-4588
Mailing Address - Fax:214-594-9930
Practice Address - Street 1:20 HARBOR VIEW RD
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-7850
Practice Address - Country:US
Practice Address - Phone:802-863-7897
Practice Address - Fax:802-863-9728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-15
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home