Basic Information
| Provider Information | |||||||||
| NPI: | 1164846945 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELKHART CLINIC, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2968 | ||||||||
| Address2: | |||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465152968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742963200 | ||||||||
| FaxNumber: | 5742963392 | ||||||||
| Practice Location | |||||||||
| Address1: | 1122 PROFESSIONAL DR | ||||||||
| Address2: | |||||||||
| City: | GOSHEN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465263819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742963291 | ||||||||
| FaxNumber: | 5742963383 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2014 | ||||||||
| LastUpdateDate: | 02/13/2014 | ||||||||
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| AuthorizedOfficialLastName: | BUSBY | ||||||||
| AuthorizedOfficialFirstName: | DARRYL | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5742963200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 100466600 | 05 | IN | MEDICAID |