Healthcare Provider Details

I. General information

NPI: 1952196586
Provider Name (Legal Business Name): ELITE IOM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2025
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 CHATHAM RD STE R
SPRINGFIELD IL
62704-4188
US

IV. Provider business mailing address

2501 CHATHAM RD STE R
SPRINGFIELD IL
62704-4188
US

V. Phone/Fax

Practice location:
  • Phone: 866-374-6628
  • Fax: 866-951-1120
Mailing address:
  • Phone: 866-374-6628
  • Fax: 866-951-1120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JENNA BLEDSOE
Title or Position: CHEIF OPERATING OFFICER
Credential:
Phone: 866-374-6628