Healthcare Provider Details

I. General information

NPI: 1144606773
Provider Name (Legal Business Name): NOEL TELLO LPTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2015
Last Update Date: 08/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 SPRINGRIDGE RD SUITE B
CLINTON MS
39056-5641
US

IV. Provider business mailing address

590 SPRINGRIDGE RD SUITE B
CLINTON MS
39056-5641
US

V. Phone/Fax

Practice location:
  • Phone: 601-473-2317
  • Fax: 601-473-2318
Mailing address:
  • Phone: 601-473-2317
  • Fax: 601-473-2318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA4118
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: