Healthcare Provider Details

I. General information

NPI: 1669608071
Provider Name (Legal Business Name): ELLIOT ROVER PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2009
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8881 FLETCHER PKWY # 280
LA MESA CA
91942-3134
US

IV. Provider business mailing address

PO BOX 2741
LA MESA CA
91943-2741
US

V. Phone/Fax

Practice location:
  • Phone: 520-429-0077
  • Fax:
Mailing address:
  • Phone: 520-429-0077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number33910
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: