Healthcare Provider Details

I. General information

NPI: 1467018440
Provider Name (Legal Business Name): ELIE JOSEPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2019
Last Update Date: 05/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 KANSAS AVE
SAINT CLOUD FL
34769-5921
US

IV. Provider business mailing address

1156 ROAN CT
KISSIMMEE FL
34759-7030
US

V. Phone/Fax

Practice location:
  • Phone: 407-891-5121
  • Fax:
Mailing address:
  • Phone: 407-953-5605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA23831
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: