Provider Demographics
NPI:1700364916
Name:ELKHART CLINIC, LLC
Entity Type:Organization
Organization Name:ELKHART CLINIC, LLC
Other - Org Name:ELKHART PODIATRY FOOT & ANKLE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:BOYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-296-3254
Mailing Address - Street 1:PO BOX 2968
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46515-2968
Mailing Address - Country:US
Mailing Address - Phone:574-296-3200
Mailing Address - Fax:574-296-3392
Practice Address - Street 1:1723 E BRISTOL ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-3968
Practice Address - Country:US
Practice Address - Phone:574-264-7180
Practice Address - Fax:574-264-1875
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELKHART CLINIC, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-31
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty