Healthcare Provider Details

I. General information

NPI: 1700217189
Provider Name (Legal Business Name): ELITE HEALTHCARE OF MUNCIE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2013
Last Update Date: 02/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3417 W BETHEL AVE STE A
MUNCIE IN
47304-7504
US

IV. Provider business mailing address

3417 W BETHEL AVE STE A
MUNCIE IN
47304-7504
US

V. Phone/Fax

Practice location:
  • Phone: 765-281-8883
  • Fax: 765-281-8884
Mailing address:
  • Phone: 765-281-8883
  • Fax: 765-281-8884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01027232A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71003894B
License Number StateIN

VIII. Authorized Official

Name: DR. DAVID SEGRAVES
Title or Position: OWNER
Credential:
Phone: 765-281-8883