Provider Demographics
NPI:1902051154
Name:ELDERCARE, INC.
Entity Type:Organization
Organization Name:ELDERCARE, INC.
Other - Org Name:CALVIN JOHNSON CARE CENTER
Other - Org Type:Doing Business As
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 PARKWAY WEST
Mailing Address - Street 2:SUITE 820
Mailing Address - City:BELLESVILLE
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 1:727 NORTH 17TH STREET
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-6599
Practice Address - Country:US
Practice Address - Phone:618-234-3323
Practice Address - Fax:618-234-9477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-01
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1400434197291U00000X
IL0023309314000000X
332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No291U00000XLaboratoriesClinical Medical Laboratory
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO103025508Medicaid
V255P(657)0911OtherVA (VETERANS' ADMIN)
V255P(657)0911OtherVA (VETERANS' ADMIN)
14-5290Medicare PIN