Provider Demographics
NPI:1689440893
Name:ELKHART CLINIC, LLC
Entity Type:Organization
Organization Name:ELKHART CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-296-3991
Mailing Address - Street 1:PO BOX 778985
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-8985
Mailing Address - Country:US
Mailing Address - Phone:574-296-3990
Mailing Address - Fax:574-296-3392
Practice Address - Street 1:6915 N FIR RD
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-4754
Practice Address - Country:US
Practice Address - Phone:574-296-3200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELKHART CLINIC, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-11-29
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain MedicineGroup - Multi-Specialty