=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043923329
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELM INVESTMENT GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2023
-----------------------------------------------------
Last Update Date | 01/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1203 N JACKSON ST
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65560-1076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-425-3062
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 191
-----------------------------------------------------
City | MOUNTAIN GROVE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65711-0191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-425-3062
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | BROOKE M BIGHAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 417-425-3062
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------