Provider Demographics
NPI:1851497945
Name:ELKHART CLINIC,LLC
Entity Type:Organization
Organization Name:ELKHART CLINIC,LLC
Other - Org Name:PRIMARY CARE AT MISHAWAKA
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:BOYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-296-3200
Mailing Address - Street 1:410 PARK PL
Mailing Address - Street 2:SUITE A
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-3557
Mailing Address - Country:US
Mailing Address - Phone:574-252-0667
Mailing Address - Fax:574-807-8845
Practice Address - Street 1:410 PARK PL STE A
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3557
Practice Address - Country:US
Practice Address - Phone:574-252-0667
Practice Address - Fax:574-807-8845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100466600Medicaid
IN227950Medicare PIN