Healthcare Provider Details

I. General information

NPI: 1962475137
Provider Name (Legal Business Name): ELIJAH FLETCHER III ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 05/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 N PALMETTO ST
LEESBURG FL
34748-4419
US

IV. Provider business mailing address

835 ASHWORTH OVERLOOK DR
APOPKA FL
32712-3350
US

V. Phone/Fax

Practice location:
  • Phone: 352-323-6642
  • Fax: 352-323-5039
Mailing address:
  • Phone: 305-301-7461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: