=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881803922
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELMA HEALTH CARE CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2007
-----------------------------------------------------
Last Update Date | 05/22/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11 SCHOUWEILER RD
-----------------------------------------------------
City | ELMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-482-5300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3015
-----------------------------------------------------
City | ELMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98541-0529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-482-5300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER OWNER
-----------------------------------------------------
Name | MRS. KATHLEEN M MCELROY
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 360-482-5300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | OA10000077
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------