Healthcare Provider Details

I. General information

NPI: 1902582471
Provider Name (Legal Business Name): TYLER ELLIOTT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2023
Last Update Date: 06/27/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

EL CAMINO REAL S, BLDG 4101 CAMP PENDLETON
FPO AA
92058
US

IV. Provider business mailing address

EL CAMINO REAL S, BLDG 4101 CAMP PENDLETON
FPO AA
92058
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-8912
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: