Basic Information
| Provider Information | |||||||||
| NPI: | 1831423284 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELKHART CLINIC, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EDISON LAKES UROLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 61 N SAINT JOSEPH AVE | ||||||||
| Address2: | |||||||||
| City: | NILES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491202207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2692620448 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2009 | ||||||||
| LastUpdateDate: | 05/09/2014 | ||||||||
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| AuthorizedOfficialLastName: | BOYER | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5742963200 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 |
No ID Information.