Provider Demographics
NPI:1750667184
Name:ELKHART GENERAL HOSPITAL FOUNDATION, INC.
Entity Type:Organization
Organization Name:ELKHART GENERAL HOSPITAL FOUNDATION, INC.
Other - Org Name:LIFELINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EX. DIRECTOR OF EGH FOUNDATION, INC
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:HOUSAND
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:574-524-7458
Mailing Address - Street 1:600 EAST BLVD
Mailing Address - Street 2:EGH FOUNDATION, INC./LIFELINE
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-2483
Mailing Address - Country:US
Mailing Address - Phone:574-524-7458
Mailing Address - Fax:574-523-3383
Practice Address - Street 1:2020 INDUSTRIAL PARKWAY
Practice Address - Street 2:LIFELINE
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-5411
Practice Address - Country:US
Practice Address - Phone:574-524-7503
Practice Address - Fax:574-524-7500
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELKHART GENERAL HOSPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11-005017-1253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
INPENDINGOtherMEDICAID WAIVER