=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194788620
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELMWOOD CARE CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2006
-----------------------------------------------------
Last Update Date | 05/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 222 15TH ST
-----------------------------------------------------
City | ONAWA
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51040-1025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-423-2510
-----------------------------------------------------
Fax | 712-423-1754
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11523 PALMBRUSH TRL SUITE 331
-----------------------------------------------------
City | LAKEWOOD RANCH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34202-2917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-758-4745
-----------------------------------------------------
Fax | 888-391-2373
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED REPRESENTATIVE
-----------------------------------------------------
Name | MR. GREGORY S BENCH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 941-758-4745
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 670321
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------