Healthcare Provider Details

I. General information

NPI: 1598672966
Provider Name (Legal Business Name): ELIJAH MYRTIL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 PHEASANT RUN TRL
MACON GA
31216-7396
US

IV. Provider business mailing address

325 PHEASANT RUN TRL
MACON GA
31216-7396
US

V. Phone/Fax

Practice location:
  • Phone: 786-771-8715
  • Fax:
Mailing address:
  • Phone: 786-771-8715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: