MEDICARE: ELIJAH INGRUM

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	225100000X	Physical Therapist	292757	CA

General Provider Information

NPI Number	:	1124566328
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIJAH INGRUM

Provider Business Mailing Address
First Line	:	10325 SPRUCE GROVE AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92131-2218
Country	:	US
Telephone Number	:	858-335-2682
Fax Number	:

Provider Business Practice Location Address
First Line	:	10325 SPRUCE GROVE AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92131-2218
Country	:	US
Telephone Number	:	858-335-2682
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/08/2017
Last Update Date	:	02/08/2017

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Directions to “ ELIJAH INGRUM ” Practice Location

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