Healthcare Provider Details

I. General information

NPI: 1295021384
Provider Name (Legal Business Name): SAMANTHA LEIGH ELLIG PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2011
Last Update Date: 10/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 3RD AVE SUITE B
CHULA VISTA CA
91910-2754
US

IV. Provider business mailing address

5905 SEVERIN DR
LA MESA CA
91942-3806
US

V. Phone/Fax

Practice location:
  • Phone: 619-589-2606
  • Fax:
Mailing address:
  • Phone: 619-589-2606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT60224802
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number39327
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: