Healthcare Provider Details

I. General information

NPI: 1770965774
Provider Name (Legal Business Name): ELITE HEALTH CARE OF JAY COUNTY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 11/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 S MAIN ST
DUNKIRK IN
47336-1250
US

IV. Provider business mailing address

126 S MAIN ST
DUNKIRK IN
47336-1250
US

V. Phone/Fax

Practice location:
  • Phone: 765-281-8883
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01027232A
License Number StateIN

VIII. Authorized Official

Name: DAVID R SEGRAVES
Title or Position: OWNER/DOCTOR
Credential: DC
Phone: 765-281-8883