MEDICARE: ELIM HOMES, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	101944	MN

General Provider Information

NPI Number	:	1528304490
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELIM HOMES, INC

Provider Business Mailing Address
First Line	:	200 LEWIS AVE S
Second Line	:	SUITE 210
City	:	WATERTOWN
State	:	MN
Zip	:	55388-4545
Country	:	US
Telephone Number	:	952-955-2242
Fax Number	:	952-955-2010

Provider Business Practice Location Address
First Line	:	400 EVANS AVE NW
Second Line	:
City	:	ELK RIVER
State	:	MN
Zip	:	55330-2604
Country	:	US
Telephone Number	:	952-955-2242
Fax Number	:	952-955-2010

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MR. JEFF DAGEN
Credential	:	RPT
Telephone Number	:	952-955-2242

Provider Enumeration Date	:	12/21/2012
Last Update Date	:	12/21/2012

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