Healthcare Provider Details

I. General information

NPI: 1205394491
Provider Name (Legal Business Name): MICHAEL ELLIOTT NEBEL ATC, OTC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2019
Last Update Date: 06/01/2024
Certification Date: 06/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 VIRGINIA AVE
COLUMBIA MO
65212-1022
US

IV. Provider business mailing address

1100 VIRGINIA AVE
COLUMBIA MO
65212-0001
US

V. Phone/Fax

Practice location:
  • Phone: 573-882-2663
  • Fax:
Mailing address:
  • Phone: 573-882-2663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2021035008
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: