1922469170 NPI number — MR. JUSTIN MICHAEL ELLIOTT OTRL

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922469170 NPI number — MR. JUSTIN MICHAEL ELLIOTT OTRL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIOTT
Provider First Name:
JUSTIN
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
OTRL
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922469170
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/16/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4621 ASHLAND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAGINAW
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48638
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-482-6869
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1149 W MONROE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST. LOUIS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48880
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-681-3852
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/16/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  5201009383 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com