Healthcare Provider Details

I. General information

NPI: 1144593252
Provider Name (Legal Business Name): ELMWOOD PE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2012
Last Update Date: 02/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 15TH ST
ONAWA IA
51040-1071
US

IV. Provider business mailing address

190 15TH ST
ONAWA IA
51040-1071
US

V. Phone/Fax

Practice location:
  • Phone: 712-423-2510
  • Fax: 712-423-1754
Mailing address:
  • Phone: 712-423-2510
  • Fax: 712-423-1754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. RICHARD T MASON
Title or Position: AUTHORIZED REPRESENTATIVE
Credential:
Phone: 888-391-2373