Healthcare Provider Details

I. General information

NPI: 1518503978
Provider Name (Legal Business Name): ELIXIR JON GABRIEL PELEGRIN FAJARDO PT, DPT, RAC-CT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2019
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 WASHINGTON CIR
SOUTHBURY CT
06488-3020
US

IV. Provider business mailing address

3 WASHINGTON CIR
SOUTHBURY CT
06488-3020
US

V. Phone/Fax

Practice location:
  • Phone: 347-633-7630
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: